GW1-2022-04857_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD (GW-1) For Internal use Only: j
1.Wdi Cti+ata'eetor hifort iota:
WA
Wall Coffins ar r1a= �••' FROM TOD6BC:aIPF On
n at.
7 ft, ft. --
NC Wen Comaama Cati&-atin Number l ® sa�u+,am sa eacws
i FROM I To ni d]3R 'ztaclaCm
company Na m
2.Well Cootfruction Permit#: r Y 9 PWM TO DtAAtb9'ER MATERIAL
Litt all applicable well comirucdon yerrsits(i.e.111C,County,Stale,Variance,etc.) rL (L �
3.Well Ute(Cbeck well asx): ft. it. tn.
Water Supply Well. 17z_ i
@pdtOm TO IDir1,MUR SLAT SUZ TII1C6Sri9M MATISLIAL
Agricultural mimicipaltPublic ft. ft. im.�
Gwd= W aleatingicooling Supply) a sidmtial Water Supply(single) (L "-
hadustsftVComn=Cial Residential Water Supply(shared) --
lgl FSSOM -,to MATMA L irdf* 1kCZ rrl uT AMBOD dk AMOtWr
Nola-Water Supply Well:
monitm,m Recovery IL Pt f
it. fL
A41ui4es Recharge E)Grouudwater Remediation i
! . ale
ArlGeahemd
uifer Storage and Recovery �5alirrity Bonier Fr2o1a To PACKPACKMATERIAL FMYI nt�.�iYs7iT neirreaD
fe¢Test �Stormwater Drainage
ft. ft.
EnwIltac
ttil Technology Subsidence Control Pt. It T
�ertnul(CloRd Loop) DTracer Tip 1xR1II.1dII%�LOG attach timal tfmil`
(lieatin aolin i2etum _Other lain under##21 12ematks Faoaq TO D eMON(vv� ®rdsemseWm gym jEdm AzF4 efo
mabz 4r3mal(e)f di:
We1131Dk _
5w.WeilClosfQQn: fY
FaoilityN);vats Naa:o Jeeilisy ID#i(if yrpracabk) �' `� 4
At
Phyeecai Add,City.
aad,Zlti .
Cassnty Trace;Iekmiticsdon No.(PIN) w'r ovsI .iT+j t —�
c
Sb.Latitude sued lometude In deVeWminuitealseconds or decimal degre".
(if vre11 field,a=lavlonz is rulI 22.L'ea tilleetiom:
�---
6.Ware)ft'Wem"4111
ennanent or [37emporary 8ipsture of Certified Well,Goatraceor Date
' k,signing this form 1 hercbv crerfif,ifiax the well(s)was(avers)camtrucled in accordance
7.la Ws a repair to aik eskting well: 13Ye6 or No o with 15.4 NCAC 02C.0100 or.15A NCAC'02C.0200 Well Comtrucdar Siandardr and that a
if Als!6 a rgD'Wr,)W nut kwwr 4VII construction infor�rmaf:ar. xplalta the ruaare of der cdP>of fhiv record has beer avor+idrd ADthe ml1 awxer.
repair under#21 ra marb srctior or tan the back of this fonn.
23.Site dkgram or aiddidonal well details:
8.For CveoprobeMPT or Closed-Lxeoip Geo€hermiml 1Well3 having the same You may use the back of this page to provide additional well site details or well
construction,only -1 is needed. Indicate TOTAL NUMBER of wells construLdou details. You may dw attach aM-Lionai pages if necessary.
dd&W'— 11JQitTil"f1Al�?1T�Slrlr'il0lda�e
4.,TpW Weil dep&.bdow,land surfu : 1� ( ) 2�h poi '.All�7V BS 'Subririt this fiihs within 30'da�s of completion of will:
Far twe/dple welts lito.aU da�.tlos.(jt!(�ere+u leraaaopl�.3(a 200 awd 2Qa 10Ci)
.cons tits fo. •- tructi'oru.ta (lowing:
10 Sftdc vtatrta'level b elowrty cab .
D of mil' '",.�v V.) - .1BMeioeaofWer.erFYeeotta'cue;laifort�sMomFtvresssia$.L'etit,.- .
1,vow,TrlW asobm a aarfr .we"+"
_ 161$Iklmii Service Center,IdsW&A,XC 2759-1617
—(ID.) :26b_d+o -lrt1 ou Welk In addition to sending the form to the address in 24a:
above,also.'subunit one.copy of this form within 30 days of completion of well.
12.Well constraeftla mod:
.---.-..--- 'ccrrtstructitxi'to the foYlowiia _. .. .,. .. ..... . ... ... �. ....._..._... __.
(io-sugar;roteuy;cabk,tLiaicf�puab,=de.j. ,-. .. : $. ,
-.—.� 131visQ6s(off' iert3eao'tasees,`ZJ-din-rouii 'Iitiere a[otitiol'I'aazggysiii,
F®Ei�uV -SlJrppl%; i.LS..t11�I,Y: .: 1636 Mill Service Cemer,Ralslgh,NC 27 -1636
13a.YQe i(gptQa) Method of teat: 26c For Water Suonlq&TnldetlgjjNaj- In addition to sending the form to'
the address(es) above, also submit'one any of this form within 30 daya of
13b..Whinfeeffen tryg+t: Arffi€rant:__ completion.of well cousLnrctien to the county health department of the county,
where coisstructed.
Ru m oW-1 North Crrolina Departmoar of Environutentril tiw Giy-llivieioa of 9Voter Reaouicos Rev and 2-22-2016