GW1-2021-00412_Well Construction - GW1_20210129

WELL CONUR.UCTION RECORD
This form can be used for single or multiple wells
I.Well Contractor information-:�.,,
ad MFDtiSt:RtPTIp\ i
WdIL Ctlntratnor Xcul •_
.\WWellCotmactorCcrtification.Number ' JORW
fROAt T4 DLLM �lTFaiA1l �s E I t� .t � n. f=. �/
Comport)-Kaine t6. '£R 'G R dfigadwma
FROM ro at,►lttert:R TxtcK. aaareaur.
2.Well Construction Permit#: `"',y�t✓ �"'�"'► ft ft. in.
/,nt nit aAljlitxshle xr11 crnxerructiwi peratiar f+.e.!ortaq•,Stare,irormnc, rjal i
ft. ft.
3.•Well Ilse(check well use): t7,SCREEN
Water Supply Well: FRom T8 DUbM= LOTSIZ T8f K.te MATERIAL
CAgricuitural f3NlunictpaltPublic
ft. ft in.
CGeothermal(Heating/Cooling Supply) ft -idenual Water Supply(single) ft. ft. in.
(_rindustriallCommerciai 0Residential Water Supply(shared) ILL GROUT'
t CIrrtcauun FROM To MA Es TM. EMOD�Ast c: t
i you-Water Supph L1'e11: ft. 'fs. tt�1tA Y
'O.Vicntsartng GReeoYen
Injection Well: Il• IL i
GAquifer Rechsrze CGroundwater Rcmediation 14,.SANID! RAVYL PACK if Fa
MAginfar Storage and Recover}• DSelinity Barrier FRaM To M Tr itiAL Eatr xsrttaa
ft. fr.
ClAquii'erTrst CStormwater Drainage Fi ft.
CEapaimental Technology CSubsidence Control 20 DRILLING aetach sdtiidanat sheets if ttetxssaty
CGeothermai{Closed Loop) D t racer Flaam TO D tP17 \Feotan itardnmu seglhoek rmt A=Ise.
CGeathiermal(Heaun Cooltn Retunt) Cpther(explain under d21 Remarks) fr. ft.
_Se tt 20?—/ fr fr
3.Date Well(s)Compirted: ft. it.
;.Well Location:J&M
t 1
Faelliq.ANtic:\mite Factiiq•ID,,(if applicable) ft.
L160 IJS " Red Rd, Mirintzs6arn fl. ft.
Pigaieal.Address.Cny,sad Zip I to� � 2 8`2 21.R RNS'
CUN47rY Parcel Identitieatiait NO(PIN)
5b,Latitude and LOMItude in degrees7minuteshecouds or decimal degrees: 22.Certification:
field,one Inlong rs sumcletr)
/ Signature afCcnified Well Contractor Date
6.1s(are)the tt'el1(s): f1fF'rrmanent or DTemporary
Isy siAnniq dus/onu.I herrhy eerltf-that the velffij ufxv Aren)rrutoraurd nt rncorelwrer
/ tr•uh 15A Nr'A('u2C..t11ou or 15A YTAC'All' Quo 1FN11 C ino�rintrnat Su+adanlc us!rhut r,
7.Is this a repair to an existing well: CYU or Ia<lo _ crips�gJthis re<rrrd hers born provided In the urN uK•tier.
11 rh,.+rs a relmr,.01 nvt ktnmw w•el trarwrncnnn nofnrraouro;antirs/dtrh,the nG�MrYV Ike {
"Pa",
tinder-21 remarks scrium or all 11k hack of thin 1i1nn, •^"'�Gam' :"' ( ::,.23rSite diagram nT additiotuel Well detaitS:
.1 "" You may use the back of this page to provide additional well stir details err%till'
S.Number of wells constructed: � n�nstruction details You may also attach additional pages if necessary
Flip s+ultrpie,Injection err uraf.lseNrr.ruAf+ls a'o!!r Q,41.l'xUt!hr sew ! htf,Qj;"�.ZU C� r.
,uhna,r rmr larat J�'i °+ 24.Submittal Instructions: r
9.Total well depth betaw land surface: 0 5 :{�(} 24a.'For All Wells: Submit this form within 30 days of completion of nefi
1 erra1ifhiple t+4tv Its,all dr/Nhs t1drlltrrnt frturnph,-3L2F/1'alid 2 f IVirI i,BnStrUrtiDn to Cite following
10.Static water level below top of casing: (ft, Division of Water Quality,Information Processing Unit,
u+,utrrtc:ttr.uhu+ tN..,nt,t� /�q l ) 1617 Nlail Service Center,Raleigh,NC 276".I617
11.Borehole dianfetem W
(In.) 24b. For lni lion Wei1s: In addition,to sending the form to the address:n 24a
above, also submit a copy of this form-uithm-:30 days_of-conipicuos,, of%veil
12.Wall construction method: {} construction to the following.
it a auger,roigy,"bit,dtrat push,ere.)
Division of Water{}nality.Underground Injection l:ontrai Program,
13.FOR WATER SlfPPLV WELLS ONLY; 1636 Mail Service Center,Raleigh,NC 27699-1636
130.Yield(gpm) Method of test:�iY 27ffilij _ mac.For Water SttDaly&Gr,alkirmal Wells: in additton to sending the tium to
the addresses) above, also submit one copy of this form utthin 30 days of
lab Disiufeeeiontppe: _�'1�1ri� Amount.�7 completion of well construction to the county health departmtnt of the count)•
where constructed.
Fain)GW-t \orris Caratina Departmeas of Enviranmew and Natural Resoutca—Divisian arwater Quality ;te%,scd Ian 2013