GW1-2022-05437_Well Construction - GW1_20220607

WELL CONSTRUCTION RECORD F
T}ns form can be used for single or mutdpte wells
1.Well Cuntractor Information:
h __ f'f _ee_nQ 14.WAT8AZ0'V
..7 lj�r (Sl' FROSt TO DESCRtPTtO\ i �
Weft('ontracr2or\act
1 J�' i l
N('Well Contractor eerrifiearian Number a� i.IIFF MATERIAL
PIVIL
Cosnpam me•Na 2b 2t'lNER CA&SEG OA
H 430
'7�7 FROM TD DL►M TFItGKA"FSs MATERIAL i
2.Well Construction Permit#: q ft. ft. is
Lint nlf orphWhk Neil analrunan peM1N8 fix.C oanly,Store,1'arroor"'.e/c./ ft ft• in.' j
3.Well E)se(check well me): 27.5CREEl1
rlyater Supply Well: FROM To DiAhIETER I S Sag THICILNM MATERIAL
ft. ft. in
+;=Agricultural CIMunicipallPublic
j❑ueothermai Featin Cooling Supply) ,..G " ft. fa in.
( 3/ a pP 5 3 ecestdencral Water Supply(single)
MIndustrlaliCommercia! ❑Residential Water Supply(shared) GROt1T
mom TO . TERLLLI rMkACEPM'rIdMMV&AMOU1%rr
i^lrrsganur, ft' pZ� �• t'l't17L Y
i'you-Water Supply%Veil: ea, ft.
❑'vlonitoring DRecovM, fs• fL I
i injection Well:
=Aquifer Recharge =Groundwater Remediation 19..SAiv1)JG Vis.PAt:K >f
CAqu:fer Storap and Recovers• =Salinity farrier FROM TO MATERIAL EMPLAMLYMETHOD
�Aouifer'!'rst OStormwater Drainage
GEaperiirencatTcchnolugy =Subsidence Control ZQ DR2LLLKGLOG aemehadditional sbeetslfaecsssarr
L-Geothermni(Closed Loop) =Tracer To tPitOY color hardnesf soilhnek rainsve•etc.l
CGeothermal HcatmZ Cools Return) DOther lain under 021 Remarks) fc, fa
_r� fa fc
o.Date Welt(s)Completed:t i��!w4 31 4900V A. ft,
i.Well J ocatior: �+
�.rarnm T'�Q�n fr. ft.
...,.iia.ih.nc:. sr Fa:•.tlip•1Dc(;fapplieabkej Eft. ft. — AIN07 a
Fawn Rd Odurnhxs ft. fc
Pi:ssic Address.Cn>,and Zip 21. EMARIJUl
i a �iq -4q . oc>EG UNII
Parcel Idemii:cation No(PIN)
Sb.Latitude and LouglhWe is degreestminuteahecouds or decimal degrees: 22•Certifcat)ow
(,fwcl!:ie1d.mu latlong fs suffietercl
t, 31
��. 5- -'�2
Signature of Conified Weil Corimictor Date
6.Is(are)the aell(s): l ertmsaeat or ❑Temporary x/mturg Ills fora,/brtrhp eerlw ilwr the xe/!(.s/xar(xehj CniArftwttrtl rll accrrrtfu+tic
xi/it lit Mt'•A(•U$',010b nr 15A'A At'Q%' W80 Iveil a imoraclrlo/da nkirds and that a
7.Is this a repair to an ettisdag well: Dees or R&O rwpt•qJ I&I ttrrord hoo Arrn&nvided in the Nei/awaer.
/i dim m a rerwr,bfi a w hikmw well crwrnr wnl»Wf»trarlan and vrplaiu the aal/1re 14 the
23.Site diagram or additional well details:
rerw/r osier..21 Irararkr xeettim fir an the hack of thrr form.
You may use the back of this page to provide additional well site details fir Drell
8.Number of welts constructed: construction details You may also attach additional pages if necessary
).,jr Imd ioph-inleetit-o sr nrnl.n'Mcnruprlc 1 t!!r ONl.F a•IIA the soRw Constrae7(att,yntt Vint
,xhm,r tin,•l,;N,t � 24.SubtnittAI Instructions:
9.Total well depth below land surfacer (ft.) 249• For AN Wells- Submit this form within 30 days o!'completion of Melt
Par widly'le it"Ovhrl all drrrh..lJafdJerelrt le inrrhy 3-t2ou'and 2Ca!fife) construction t011le following
io.Srarie lister level below cop of easing: C� r ((�,) Division of Water Quailty,�Fnformation Processing trait,
1t 1iu1Cr l::iyl,.ahr„r,u..a,�.arc••// 1617 Mail Service Center,Raleigh,K 27699-1617
11.Borehole diameter. [3 t g(ia.) 26b.rhr Iniieetion aeng: In addition to sending the form to the address in 24u
above, also submit a copy of this form wichm 30 days of uumplaioi: of will
12.Well construction method: �h[S�'Q+� construction to the following.
i; 41r"t push.Vie.)
Division of Water Quality.Undit;rouDd fajccdoa t:oatro!Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail[Service Center,Raleigh,NC 27699•1636
13a.1'ieid �fY1 Method of test t 240,FarFar Water So'
&Geotber�ual Wells: In adduron to sending the tors tit
teem)- the addras(es) above, also submit oho copy of this from within 30 days of
13b.Disinfection type: Nkorive- Amount _ � of well construction to tile county health departmenter she count\•
where
For,GW-i Vanh Caralina Department ofienviranme and
d Naturai Resousees-Divleion of Water Oust ity ke.,sed Jan 2013
4