GW1-2021-06665_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD
This form can be rued for single or multiple welts
I.Well Contractor Information: �j �!�,
1 1{(1 5 Y C �""�•J 24.WATER ZONES
FROM I TO I DFSCRIPTIp\
Well CCC ootractur(�Naame, f � "' fr.
III
NC'Well CounttrracttorrConiificati+onn Numbtr pti'�R CJ�J1tO� FRO OUTER CASING tot Ot!-e2ied At2lt NTH 1Qf�ESS NER fifA rtATERtAL rt
_ i— V t i I t JY l I I ft,
j ft,
to f in_ � al v
Company Kama 16.INNER CASING OR TITR . t eiosed too
('1 1� r"� FROM TO DIAMETER : THICKNESS vIATERUL
2.«'ail Construction Permit#:_. �/ ft, g; in.
1.w nit appircvhir xrtl cr,tsrrui tint prnrrixs(r,e.(•anars'•Sum,1`armncr.etc./ ft ft in
I
3.Well Use(cheek well use); 17 SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOTStZE I THICKYEss 42ATERtAL
CAgriculturai 0MunicipallPublic ft, ft. in.
(Geothermal(Heating/Cooling Supply) ft. in.
j2fResidentra!Water Supply(single) ft.,
DIndustrialiCommercial (Residential Water Supply(shared) 18.GROUT
i
FROM TD :NATERLiL- EalPL�CEME.IT METHOD&A1lOi:h'7'Ctrrtgatwn it. 'fr.
\op-\Vetter Supply Well.
I(.Monitoring CRecovery rr rt,
injection Well: ft. ft. i
CAqutfer Recharge CGroundwater Remediation 1 19.SANDIGRAVEL•PACK lif ancilicablei
Ookgwfer Storap and Recovery (Salinity Barricr FROM To I MATERIAL E+iPI.AcEMes•TatrrHOD
ft. ft.
CAquiferTest MtonmraterDrainage
CExperimental Technology (Subsidence Control 20,DRILLING LOG(attach additional shcets if necessary)
(Geotlft final(Closed Long} C3Tractr FROM I TO I DESCRIP7'IOX toter;hardness,s*Wrock st t,-rakt siat.etc.
CGcothcinial(Hcaltna Cooling Return) Other(explain under ri2) Remarks) tt. f°•
t.
4.Date V1'clt(s)Completed: l,Jire7 J+ QJW
5.Well Location:
Wi11� i DMORPA RD61
Facility0uucr"Nome Facility iDe(ifapplicable)
05 WnfflSk , Dkivr, Mill (Slorinan ft. ft.
Ph)sical Address.Coy,and Zip 21.RENIAW
lT- lk P(5-40
Count.% Parcel identification No (P)NI )
Sb,Latitude and Longitude in degrees/minutes/serouds or decimal degrees: 22,Certification:
(,i wail field.one)aL long is sufficient)
G, Signature ofCcnifitd Well Contractor Date
6.Is(are)the wiii(s): 6irrmwnt or ❑Temporary y•,si,iaa,ibis•nren.1 hereh•coal!•rhur the tali(., aas rert•'cvti.clruttrt/ni crcix,r:lrurt:
By signing.4 ! l l / (s .r
x•rrh1SA•Kt'�t't�?<'.t1lOtrnrlSAYI'.it`1)Zt' U21TtrtFeitt'rruarr+rm,aSrnt:irir<fruialrhri+ri
7.1s this a repair to an existing well: (Yes or Q4'o cw1Jt of rhtr recnral has hero luavialed ru+he x rl!tx•nar.
It+1104 L,to re/xnr,fill not kamrw well crarsirucnaa rn/nrinaarm and vrphrin tht,nature a/the
rerwtr antler_,21 maiarkv.securon tr an the hark of tttly fnrar. 23.Site diagram or additional weltdetails:
1 You may use the back of this page to provide additional Weil site detail,or well
S.Number of wells constructed: i construction details You.may also attach additional pages if necessary
1•i,r aridarle t,rec,aur ur nrur•tr'<>lor.rnllt/t t,eUv OA7.1'n•trh Ibe same rn isimclion.Can van a.
,uhaw utv lurnr 24.Submittal Instructions:
9.Total well depth below land surface: tY (ft,) 24a. For All Wells: Submit this form within 30 days of completion of\tell
how andot4e t l&list all drpth-.it dillerent(er naph-3fi2110 and 2 ie 101f) construction to the fitllowina
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing emit,
�/+,ut f2•,cri trhtrratn,arF.era: // 1617Mail Service Center,Raleigh,NC 27699.1617
l I do.rehoie diameter: lD , (in.) 24b.For..Iniection NVelI in addition to sending the form to the address in 24a
above, also submit a-copy of-ihis form, mithin 30-days-of como)ction of-wolf
12.'Well construrtion,method: { {� construction to the fokiawing:
it eauger,rosary.cable.tiiicat push,etc.)
division of Watet Quality:Llndtrground Injection Control,Program,__,_
13:F4It:ti'ATER SUPPIN WELLS OILY: 1636.,Lail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm} igethod of test: t ! 24e,Ftlx 14'ater Supply At Gsothtrnaal Wells: In addition to sending the form to
� �Gt— the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection type: C�I O rlyll f_ Amount:_. completion of well construction to the county health department of the county
where constructed.
Form Cr W-3 Kanh Carolina Department of Euvitotimtns and\atttra!kesouues—Division of Water Quslity Rey sscd tao 2013