GW1-2021-00564_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD t
This form can be used for sin_te or multiple welts
1.weli Contractor Information:
l 1 en h� 14.WAFER ZO!VES
FROM TO DESCRIPTiQ\
%Yell Contractor Natal
ai i
wrCertifitationNt++Tiber 55.OUTER CAS f'YG(for mnLieasedwells
\C Well Contrae OR LINER sfa le
FROM TO DIAMETER THItSCti13S MATERIAL t'
4 (I tin ® v 1
Compa+g flame 16.INNER CASING OR TilBihi aa1'elosed log
�.( n (� Q FROM TO DUMET£R THtCK4Es5 MATERIAL
2.Well Construction Permit M t 1 y 0 49 L w ft' ft. in. )
Ittl all nrpk'cvhh,tell cyntsirnt9ian permits fix.('orrnn',Sinte,lrm'ionee.etc./ ft ft.
3.Well Ilse(check well use): 17-SCREEN
{{'ater$uppiyWell: FROM TO OTANI ER SLOTs12E TRICKS} MATERIAL
ft. L ft.
OAgriculturai C)ivlunicipal/Public
ft. in.
+3Geothennal(Heating/Cooling Supply) �esidentfal Water Supply(single)
ft.
�lndusirlaliCommercizi ❑Residenttal Wares Supply(shared) 18 GROLT
! FROM 30 MATERLLL E\iPL4CEMENTMETHOD&AAtO('NT
1^.lrn¢anon fe a�-ft. SIX
Nou-NVAter Supply Well: tr• te.
0M. 0nitoring CRecovery
i Injection Well: R• fr. i
GAquifer Recharge --Groundwater Remediation .19.SANDIGRAVEL PACK if liesbie
FROM TO MATERIAL E�tYIaC'EME\T>tErt10D
CAquiter Storage and Reeoven CSalinin Barrier
MAquifer•test GStormwater Drainage ft ft.
CExperimental Technology OSubsidence Control 20.DRILLING LOG attach additional sheets if netsssary
Z!Gcothermal(Closed Loop) OTraeer FaoM TO I DESCRIP370\ toler,hardness sot!lreckn e, rainrire e+c.
CGcothermai(Seat m Coof I ng Return) CClther(explain under d21 Remarks) ft. fc.
4.Date Well(s)Completed:
S.Neil Location:
Tail An f0%
k_
Factlit�.flwne:Nime f:acilir•iDe(ifap j-fvplieable) ft. ft. ^r.c
Mrs l
Par k -r Form Rf i ft. ft.
Pigsieal Address.Ctg,and Zip 21.REMARhs
Lincoln 1oa4b9
(t,❑ntt. Parcel ideniitieatiott No (PIN)
5b.Latitude and Lonotudc in degrees/minutesisecouds or decimal degrees: 22.Certification:
(Irwell field,vile latlong is suf cien..)
wre ofC
S+gnacnified Wcl)Contractor Da[e
6.Is(are)the well(s): i4ermanent or OTemporary yy,rlttuug this form,/hervhy comfy'drur the u•eNL,y)tat(+tiny rwipirxurd tit uccuralwuv
with 13A Nt"A('0C.o101;nr 15A V A('u2C 01110 lYri!f'nnrrrxcrxxr Srrnxlunli and thin ft
7.Is this a repair to an existing well: 13yes or J'o cvpi u/Mrs revord has hero provided fit the well imner.
/l lima is a report,fill nun kurmw well crutanrtrc nrnt rrrforinantat and.xphdn die xaxrre(If the
ropUir under.,2!rr+norks.crcnnx or ar Ilse hark of this fnrxi. 23.Site diagram or additional Well details:
You may use the back of this page to provide additional"'tit sue details ur\veil'
8.\umber of sells constructed: construction details You may also attach additional pages if necessary
For audtrple ntteolan err unit-nYYlcnrtrpph tt elk OYI.1'a'JJP 1he S?Ate CMiCrfttCtfnll LY711 gait
24.Submittal Instructions:
.uhnist i m•lurnr
9.Total well depth below land surface: 30 5/ (ft.) 24a. For Alt Wells: Submit this form within 30 days of compicuon of%tell
Vnr nadttple it ellslrsl all depth.,d different feramph••3920W OM12{ei Ilarl construction to the following /
Division of Water Quality,Information Processing Unit,
10.Static seater level below-top of casing: --�D - (ft.) 1617 Mail Service Center;-Raleigit NC 27699-1617
11 v at:r It el r,ahmv a.+eu g.rr.,"
tI.Borehole diameter: (in.)
24b. For fnieetion wens: In addition to sending the term to the address in 2Ja
�I/ �
}� above, also submit a copy of this form within 30 days of cvsnpleuo+: of tvcN
12.Well construction method: i CZ� construction to[he following.
(t a auger.ralary.cable.dirt push.etc.) Division of Water Quality.Underground Injection Control Program,
13.FOR{WATER SVPPLV WELLS ONLV: 1636;Nail Service Center,Raleigh,NC 27699-1636
I 1 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm �4ethod of test:) the address(es) above, also submit one copy of this form within 30 days of
h _ Amount completion of well construction to the county health department of the county
13b.Disinfection type: where constructer!.
Ret-sod 12it 2111 i
Fomt OW-1 North Carolina Department of Environment and Natural Rescue:=—Dia ision of Water Quality