GW1-2021-06677_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
).Well Contractor Information: �°_ "o Y
�C.JJ 114.FROMATER ZOIVPS a�RtPrtat
I To
tt'dll Commoor\asuc
NC Well Contractor Cerri&anon,Number G;f, `2 � CSC IS OUT ING CAS fformptti.med ORLtNER tfa
1Ct Ram TO DUMVI It I TagI -gms ata VI AAL 1.
1 fs. ft. f Im' 01 r-
Comparr Nmne ..16.INNER CASIIt G OR momdiet
af6FROM TO DLNHErER TNtCK.NTS.0 MATERIAL t
Z Well Construction Permit#: ft. ft. hL !
l.i,l all appkWhh;Kell cmurirac•titru pennitt(i.e.(ounry,Stare,J'arimice.ele./ i
ft. ti in.
3.Well Use(check welt use): i7 SCREF�
Water Supply Well: FROM TO I OTA&IMR I SLOTSi2E I THICKNESS f MATERIAL
QAgricuttural II unicipal/Public ft. A'. in.
Q
j 00eothermai(Heating(Cooling Supply) Residera:al Water Supply(single)
j 1nduStrillfCOmmerciai 0Residential Lt ile'r Supply(5hared) i'RO ROUT TO TER M T OD&.l�tOt:\"r
1^Irrigation
l Non-Whiter Supply R ell: ft. 'a`+^fa fY1\X
i fr. te.
[).Monitoring O Recovery
1 injection Well: fr. fL i
i
0Aquifer Recharge --Groundwater Rernediation I I#.,SANDIGRAVEL PACK;lif soplicsiblel
^Aquifer Storage and Recovery DSaltnit r Sauter FROM TO MATMAL E�1PtACEMEYI StErftap
ft. fx.
I JAnlliler fCSt 0Slonmwater Drainage
' ft. ft.
{C:Experimental Technoiugy aSubsidenee Control
20.DRIL0.CLOG(snub add hiftuy
^Ceothermai(Closed Loop) Caom TO DES O\ a r, rain tire.tic.
CGcotiicrmai(FeatingfCcoling Return) 00thcr(explain under 021 Remarks) fL tt
r ft. &
4.Date 13'ell(s)Completed: ft. ft.
i.Well Locatiorr: fr.
C��ta nas (nt1, ft. ft.
aeilisy.p%,cse:N::nt Facility for tifapplieable)
ft.
?F�IAddz.Cray.and Zip 22.REMA
Comity Parcel lderuiltmion NO(PIN)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification: ,�/
(i:licit field,one tat tang is sufHesenti M. � . aj Dal
Signature ofCcrlified Well Contrnetar Date
6.Is(are)the aell(s): d4elmantnt or OTemporary
&y xigning,this fanu./kemhy errrffp that the x ellf,,,Hat 61VAt rtiavirutird in xttrrmAmc;:
a-ith i3A NCAC•a2('.o14u nr 15.4 AT'A('02(' 02119)freil t'rurrtrr ciani.Urualrrtb wul tiara p
7.Is this a repair to an eXiSting well: CYes or 940 imps q Au vtyrrd hat barn prnvided to the u r/t ii i ner,
//rla,rz a refwrr.(rl/ase kirrran ieell uimimrmrul rrrfurrnatairt and a:rpinGr ilia owl re ref the
rerJurr antler::2/minarrtr,recrtr+n or roi 11W hack of this hirer. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of weds constructed: construction details You may also attach additional pages ifnecessary
k nr midirpl,•roirc iwn or JrrUr•tt'<>ic'r.Yupjr�t'U 1//r 0, j)r p•rlh tilt.CQArC rrN3itrt#'}1alr,iY71t tart
,uhnui rJnr/J;rnr 1 24.Submittal Instructions:
9.Total well depth below land surface: {ft.) 24a. For All,Wells: Submit this form within 3U days of completion oi'%tell
For inidolddt,ellr hn all depik,ifdif/ereltl(ewisipir•3.1^�tr2tlh•a+ul 2 CRIfits'f construction to ti>e foiloWing
10.Static water level below top of casing: l0 (ft.) Division of Water Quality,,Information Processing Unit,
/1 ti rat.-r i,:•c l t,abort a u..nrR.ere,•..//" 1617.Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter- <U (ia.) 24b. For!auction%Veils: In addition to sending the form to the address:n 24;
above, also submit a copy of this form %%ithin 30 days of completion of%veil
12.Well construction method. �n�QY construction to the following.
i.a auger,nitsy.ctbte,dsmt push,etc.)
Division of Water Quality.Code Irground Injection Control Program,
13.FOR-WATER SI'PPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.l'iMd(tepm) h[ethod of test:��j 24e,,For Wader,Salt y&Geotbertna)W Ls: In addition to sending the form`v
tits address(es) above, also submit unit cagy of this form mzhirt 30 days a.
j 13b.Disiutrction type: C OY'm? Amount: completion of well construction to the county health depanniont or the county
where constructed.
Form Gw-t North Carolina Department of anvirenment and Natural Rosoums-Division of Water Quality kc%lud Jan 2013