GW1-2021-03326_Well Construction - GW1_20210603

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WELL CONSTRUMON RECORD(GW-D For Internal use only.
i. Contractor Information: � }
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WellComrsetajrTUM ER M TO Awscawnox
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NCWe31ConuadarCertdiratioaNumIter 15.OUTERCASM maw OR1.115ffit d
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Company Natae & in.
16
2 welt Construction Permit#: FMM To I DIAMstsa z»:ss un�u►i
Listall ap icable wrll as n prrarits�e UIC Cons%she,vwz etc) (> S go S E� t j0 v
3.well Use(ehechwen rise): S
fNP
appty well: 17_SCREEN
FROM To D7Mt� SLarSR8 TMCKKM hTA3F8rAL
Larl
laual �MraricipaUPublic 20M 3d g off" b l� 9c,� 1I� e
mal WeatmW/ oohng SDpply) [3RendwtW Water Supply(sirgle) R R :n
ial/Commercial DResideutial WalerSupply(shared) 38 CROITf
_ ]FROM TD MS1t8iAL 131Fr.A�rII� PAEMOD&AMOUW
t�Supply�wen: 0M 15 s. oR���R �-1V"r`rkp
we Recovery 15 ft 119 & "-Wen:rRecharge �GrarmdvvaterRemediation 1$SANaIGSAYBLStorage and Rmovay [3Salmity Barrier FROM ro MK ERMLTest [3SWramatwDrainage 1'� R '3 nadd Tedmology 13SubsidenwControl Rmal(Closed lAap) [Tracerrmal nglCoalm Rdum) tom( under#21 Remark
5-04 5`al O 1 la $ -5TO N e
4.Date Wen(s)Completed: Wen aw fn 1 ' 5 , 8 (� g 1�1t s r 11 G t
sa.Wen lecationc 5 /o Clynoiel st&
W-+0P Cu� R fL 15. $ TM P-N A G 51 It clRy
Facr1Qy10wnerName FacWw UV({fgTHcab2e) S & 3 a tz Tlkv • Rt7uwt., e-I Ay �s t l'I"
31D 50LA+�\ ST+Rre,+ 0.e. 10, G, M ft- Gt 14te SWNd
ep>nuy ran et laemfific2fmn No:trno
5b.Latitrtde and tongetude is
t*f we11 '°� ' ) 22 Certification:
3 5 ,9sas3� �Q : Do O Z� Ing��t;:3Cbn Pray,iio ng 13nit
N w C) r i��E�TIOn r. O( O ` d�
6.IK=e)the wens Petmsaeat or OTemporary Sigaanae ofCe:tified Nell Coanacmr I i?ffie
BY sigahtg this faun I h eby terfiP drat the vwff(s)um(ear)eructed is aaavrdanae
7.Is this a tepee m as e> g we9: Dyes or NO with I5AACAC 02C.0I00 or 15ANCAC 02C.02W Wdl Caav aczFw SMndards and dmta
Ifdtis lea arpair,fdl ouf lnaivn mpcorabrexiarr btfafntatlmr ap1a�dr natmm ofthe ewoffkfr n=rdhar been p vn&d to dL-wBownw
,rpwrmz&r 421,cvzw*Fsecow ar en the back of ls,font. 23.Site diagram or additional well details:
S.For GeoprobeMPT or Closedhoop Geotbwmd webs hn mg the same You may use the back of this page to provide additional well site details or well
constriction,only l.GW I is Deeded. indicate TOTAL NUMBER ofwens construction details, You may also attach additional pages if necessary.
drilled 2 s 3i_MMMAL HiSMUCTIONS
9.Totalwen depth beh w feuds; O
ewe-3g2oo'mtd2a@I007
00 24a.For An Wel;s_ Submit this form within 30 days of completion of I
FaramlCple,xltstistaudepdaif ( uctiorttadrefulIo Sub f
M Static water to p ofc *V. ' (iL) DivWon oMster
�mterlerd isabmt $ 'Iatormatrsir Usk.ff ['3
6 1617 Mail Service Center,Rdeigb,NC 27699-1617
l!.Borehole diameter: ( L) 24b.For Iniection wens: in addition to sending the form to the address in 248
12.WeV conststaien f'j u$t? above,also submit one copy of this form within 30 days of completion of well
(ia svye+row,cable.duvet t�h.etc.)
Tonto the following; `
Division of Water Resources, lads nand Injection C ontrnl Program,
Fl3R wATD:R SUPPY.Y WELIS(1NLY: 16361t7ar7 Service Ceattr,Rategh,NC 2769946M
13a Yield(gpm) Method of test: 24c.For Water Saoaly&Iaiee6on Wens In addition to sending the form to
Disinfection the address(es)above, also submit tone copy of this form within 30 days of
13b type Amouft wnplction of welt construction to the county health department of the county
where rmrstructa
i
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