GW1-2021-04109_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD F �-
This form can be used for single or multiple wells
I.Well contractor Information: p t'
�i)ly 1 S IUV j t3LYeC hC .WATER ZONES
FROM TO DESCRJPTTO\ �
ft. ft.
Well Cositritctur Name i
n ft. ft.
�('Weil Contractor Certification Number ;FROM
UTER CASMG for fanldsed we113 OR,,tt M TO D4IMETER THtCKtiESS MATERIALZ F- wit t) I I VI(j ft. 1 i- 011 v '('ompany Rama NNER 6 KG OR T{)BIN therms!clI��� TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t ft. ft. in. i
1
Lm..t all apphwhh,tieil onalruc•liun Permits(I.e.(bunn,Stare.Irarloacu.etc.) ft. fL in. I
3.Well Use(check well use): I7.SCREEN
Water Supply Well: FROM TO DUMETER SLOTSiZE TtiTCKNESS MATERIAL
ft, ft. in.
[Agriculturai OMunictpal/Public
ft. ft.
[Geothermal(Heating/Cooling Supply) 4siderltcal Water Supply(single)
[industrtaliCommerciai [Residential Water Supply(shared) 19.GROUP
FROM TO MATERlAi EMPLACEMENT METHOD&AAtOC�1'
Cln•taauun ff• a�j ,fr' M1X Y
Xou-\Pater Supply Well: ft, ft.
0M. Oriitonng CRecovery
ft, ft. I
Injection Well:
[Aquifer Recharge --Groundwater Remediation 19.SAP(DiGRAVEL PACK if a licable
FROM TO t MATERIAL EMPLAC•EMENI'MrI1100
OAgwfer Storage and Recovery OSahnin•Barrier
�Aquiftr lest [Stormwater Drainage
OEaperimental Technology ❑Subsidence Control 20.DRILLING LOG artach addidottal sheets ifnemssary
CGeothermai(Closed Loop) OTraeer Fao�i TO DES T70Y colon hardness,senvrak n a-rain sic,etc.
[Geothermal(Hcaun Cooline Return) Cs Other(explain under 421 Remarks) ft• f°'
�j
ft. ft.
4.Date welt(s)Completed: O lla � @Q'
�.Well location:
17�irirk lmn SR
haeilitv0%,tic-Nninnt r��p i sciligiD-(ifappliesble)
LU
1 A ft. ft. A J J
Pit stew ddress.Cn%,and Zip Il.RE v1ARIiS ., `„e ir,,^ tJtZ
Parcel Jdeilfiticatiusi No(PIN)
Sb.Latitude and Longitude in degrees/minutes/secoteds or decimal degrees: 22.Certification:
QYwcp field,mu latlong is sufBeten:)
./ Signaturen ofCcified Well Contractor "Date
6.Is(are)the well(s): $Permanent or ❑Temporary By,siWung this flrar,I herthy certify that the srel!(..j uri (wen)l•n,t+vrnurd n,tncnnlim,-
11 uvdr 13A.A1 •A( U2C.l)l0u no,IS.A 4l'Al'a7(' WON It'ril f "Wrtl)ant}raudnrds and that
7.is this a repair to an existing Ityeii: Cyes or ■�O Lunt uJ they reconl huv hit a provided to the xrh uawer.
11 tine ra o rrpmr,.fill nut kiumw Nell Lrnt..•rruc•nrnt mr/lilrmnatman and erpleim the naitere u)the 23.Site diagram or additional well details:
repair tinder:�21 minarkv.vectmnn or nn the hark gfthk forin.
I You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details You may also attach addntonal pages if necessary
1•iu nudnpk ogeauro ur nnn•uz>h•r.rnpplr a elh ONJ.i'with die.ratite railvirlictinrt.y'an Call
+uhnuf unr Jnrvn 24.Submittal Instructions:
QQCJ'
9.J'otal well depth below land surface: lIC]V (ft.) 24a• For All Wells: Submit this form within 30 days of etlinpletWn of%tell
1 nr nralaple twIlvh.il all depth.,tl dtllervill itextimph••3@201l'alit/2!7 iou•) construction to the foliowing
)iQ.Static water level below top of casing: C3D (ft. Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,KC 27699-1617
ll,+at:•r lyre/r.u/inrr t onto}.era.+e.. '
24b. For lnieetion Yells: in addition to sending the i'orm to the address in 244
11.borehole diameter: W (in.)
above, also submit a copy of this form within 30 days of completion
of%vcA
12.Well construction method: AAar construction to the following.
(i a auger.ruts•.cable,dire:i push,etc.) Division of Rater Quality,Underground injection Control Program,
13.FOR RATER SVPPLV WELLS ONL!': 1636 Mflit Service Center,Raleigh,NC 27699.1636
I t 24c.For Water Sunniv&Geothermal Wells: in addition to sending the form to
13a.Vield(gpm) Method of test: the addresses) above, also submit one copy of this form within 30 days of
ChloranP_ Atnonnt:�3 completion of well construction to the county health department of the count),
13b.Disinfection type: where constructed.
Re.+scd Jan 2013
Form GW-i North Carotino Depanmcnt of Environment and Natural Resostroes—Division or Water Quality