GW1-2021-04427_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD F
This form can be toed for single or multiple wells r
1.twee contractor Information: n t'
(/i L'S tUV j ULY �QC&L FRIIIOM
WATER ZONES
FROM TO DESCRIPTION �
Well Contractor Nauu ft. fr. j
a ft.
fl }5.OUTER CASING for mtDI eased R '.e _ OR LINER if A
N('Well Contractor Certification Number 4
FROM TO DIAMETER THtCK.tiESS MATAT
ERIAL �'!
8 4, F- wti I .L)Yi I r,G o ft. 3a fr. ',
( In. _ ai I PVC
-
Company flame
16.INNER CASING OR T{18i1t titerfml closed-!oo
FROM I TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: ff. ft. in.
l.r.,l all applievhlr hell c(nclrucliun perinilt fix.(bunp',State,I ra•ranc..ele./ ft. ft. in. i
3.Weil list(check well use): 17.SCREEN
��' ter Supply Well: FROM TO DUAtETER SLOT 512E THICKNESS MATERIAL
k. fr.
S1Asricultural CMunicipa)/Public
CGeotherinai(Heating/Cooling Supply) CResidentfal Water Supply{stogie)
ft.
MlndustrtaliCommercial ❑Residential Wattar Supply(shared) 19.GROUT
FROM TO MATERIAL'. E�IPLACEMENTMETHOD&AhtOC1T
Ctrrtaation aU` ''ft.
tt. 1�1X Y
Nou-Water Supply Wall:
Milonitonng C Recover•
ft, I
Injection Well: ft.
CAquifer Recharge --Groundwater Remediatton 39.SA D/GRAVEL PACK: if applicable)
FROM TO I MATERIAL EMPI.AC'EME\TMETHOD
CAgtufer Storage and Recoven' CSalmiry Barricr ft, fr.
--Aquifer"test UStonmvaterDrainase ft, ft.
GExperimcntai Technology ❑Subsidence Control 20.DRILLING LOG snitch additional sheets if necessary
Geothermal(Closed Loop) OTraeer Fast TO DESCRIPTION(color.hardneiss,soillrock tyvt,^rai+r sir,etc.
CGeothcrntal(Heating/Cooling Return) GOther(explain under 421 Remarks)
- ^ � � 1
3.Date V1'cit(s)Completed: �( It ft. ft. �m
5.Well Location:crow �i etas �-ar m LLC
rrke i G ltl
Iaz:dih.Otate:Name Iraciliq•iDe[if applicable) ft. ft.
I I V GUI-�(l JJf ft. ft.
igsical Addre 21.REMARKS
'gaup. Parcel idemiticationNo (PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(dwell field,unc tat long is sumc+enr) —7- 9 -Q I
/ Signature of Certified Well Contractor Date
6.is(are)the well(s): (4Permanent or []Temporary yy.rlg,,,,ig this loan,/herehp ceri!6-thin the nel/A+ nrr;(it-ere)cnu`irmied to uuurrlwier
With ISA Nf'A('tl2('.olot)m•15.4 M'A('a2(' 021111 lVed('unurueyeuu,Crnulnrrli unJlhut u
7.Is this a repair to an existing well: ❑Yes or 19:'0 cunt q1/her recnn)hag hrrn prnvidrrl ru thu xrN uxv+rr.
/J film ra a reflain fill nut kum,w well crutstruellou 10�frarrnarrrm and ecrp/uNi 1!m noire q/th• 23.Site diagram or additional well details:
repair under,=2l malarkt•aecltnn ar nit the hark of IhJ.c Inrut.
' You may use the back of this page to provide addiuonai writ site details or well"
R.Number of veils constructed: construction details You may also attach additional pages if necessary _
f ur undnplr 79
wJrown ar nen•waler sapplt•a ell+ONLY s•!1h 1br.came ramtruclian.poll c•an ,``
24.Submittal Instructions:
,uhnut unv/urnr
I w (ft.) 2da• For All Wells: Submit this form within 3U days of completion of trell
9.Total well depth below land surface:
I•iiruiulal>le u;!lrllrrall depth,r/dr/lerota fr.rauiply.3f 2un'and 2!(IOU'1 construction to the following
10.Static water Level below top of casing: /1/0 ft') Division of Water Quality,Information Processing gait,
( 1617 Mail Service Center,Raicig)I,NC 27699-1617
/J„utrr h•rc•I ra uhrn'r r warn}.oar.. '•
2db. For Injection Yells: in addition to sending the forth to the address in 2.1a
11.borehole diameter: �iJ (in•)
� above, also submit a copy of this form within30 days of completion of well12.Well constitution method: Afar win
construction to the follog.
It It auger,nua.•y.cable.direct push.ctc.) I Division of Rater Quality.Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR RATER SCtPPLY WELLS ONLY:
t t 24c.For Winter Sunniv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm)0 Method of test: l' c �6v� the address(es) above, also submit one copy of this farm wahm 30 days of
Chloran _ Amount: 3 OZ completion of well construction to the county hcalth depannwrit of the county
13b.Disinfection type: where constructed.
ivision of Water Quality Relrsedian 2011
Form(}N•'-t North Carolina Department of Environment and Natural Resource-D