GW1-2022-06189_Well Construction - GW1_20220620

WELL CONSTRUCTION RECORD F
Thu form can be used far sine[e or muftipic welts
Well Contractor j Information-
worm Sf ULfQCC 13.WA7SR•ZO*cES'
1 TO DFSCRIPTIO\ i f
Wall Contractor Na,:tc ft. ft. j
�c weU Conoacmr Ccnificuion Ktrmtur 38.OIJ.TER C6MM fer misfe•et;l webs OR LINER a
FROA7 To DIAMETER �ESs "TA ,•1
1 rt. tx. i a4 y
Olt
FROMDIAAttTER TFttC�tA't'SS•- ...atATERtAL ,
2.Well Construction Permit#:S I I To
ft. fr. • I
I.r..r nlf appk'cahlr xe11 wasiructituj permits fi.r.[orenq,State,lrorfanu%etc./ ft• ft. in.
3.Well Ilse(check well use): 17.SCREE.
1�raterSupplyWell; FROM T DIAMETER •SLOTMXt- THICfCYESS Jt+rERIAL
ft. ft. in.
(]Agricultural C3Municipal/Public
i OGcothennal tieatin Cooling Supply) JResident:al Water Supply single fr.
(' � o PPF) PPY( ) .
i dlndustnaliCon:mcrclai ❑Residential Water Supply(shared3 3t3.GROUT '
t FROM TO :/7ATERLAL 1PLAC£�31=1T 1>,1t;TltOD&AMOC'\T
!,^.lrri¢at,on fr. ad 'fa mtix r
Nou Six Well:
ia'vlonitortng ❑Recovery -
I lnjeCt{On Wl1l: - '
MAquifer Recharge "Groundwater Remediation 19..SANDIGRAVEL.PACIC if
FROM TO MATERIAL E?tPtaCEMEYINSriioD
I Od ggwfer Storage and Recovery GSalinity Barrier fr• n,
i
I 0Agt,ifer Trst u$toffilWater Drtna:e fe Fe
OEaperhiiental Technology MSubsidence Control 20.DRFLLUdG LOG atuth additional skeet:if tueessa-
{-jGeotltermai(Closed Loop) []Tracer a.OM To DESCRIPI•to -min size.etc.)
i CGcotherntal(Hcattna Cooltn Return) (Other(explain under 021 Remarks) fa it.
fa 2
3.Date Well(s)Completed: k h `"+"f 5e, "\
S,Well location: fr. ft.
W ft. .—fr. .`,, Q ' O22 .
Factlitl.iAu,e:Name Facility FD=(Ifapplieable) ft.
►f:1 rn ova .� ft. & v�1aGOG
Pi sical Address.Cnl,and bi 2t.REX431tla
Parcel tdeluilicationNo(PIN*)
Sb..Latitude and Longitude in degreestminutee/secouds or decimal degrees- 22.Certification:
(tfwcll field,utu intlong rssuf>:aetetsl —'
Siglnnire gfConified Well Contraclar Daft
6..is(are)the well(s): iKrmanent or MTemporary gy si.wang ibis•farnl.I herrhp eerlify thul the wel fi/oar 61-el y CIUMIrattrd ft)arrc'rrralwtrt
nut/r 15A Nt'AC'an,,010u nr 15d 1rj'AC-fj%•tl?ila)r'eil C in,etre etmu Uandrrrtb and shut a
7.is this a repair to an existing veil: O Ves or ;/NC W0.of this rem ud hair hero pinvided in/but Krl1 ax•ner.
!/tinm t,if repair•,fill nvr kurnvw well cra.7rucnow informamin and rsplatw the nuiare elf the
repurr unde,21 mmarkr.ceettnn w an the hack of this form. 23.Site diagram or additional well details: _
You may use the back of this page to provide Wditlonal wtill s,ta dctails ur%%vil'
8.Number of wells constructed: construction dctails You may also attach additional pales if necessary
l:::r nrlirple tulritu:u or unn•irahv.rdpph•a elh ONI.F'u711:rile Same ctlnwilt7fatl,gall call _
n
,ahaw ewer Juror 24.Submittal instructions:
9.Total well depth below land surface:V Q� (ft.) 24s. For Alt Wells: Submit this firm within 3U days of cumpietwn of hell
Fnrtimbry4euoAhrlalldepth..ildrllerenrleamph••3r201YO&I2 Cif iMP) construction tothe following
+RSeerie.- $ter-level-below tagaf-cash : �Q— —(ft.) Division of Water Quality,Information Processing L'ai2,
1617'Metl Service C-iRe ,,Ralefgh;"C-2760"'617"'—
!l xurr testae 1.uMnr.u..u.},n.e' -
11.Borehole diameter: 1 (F..) 24b.ForInfection Welts: In addition to sending the form to the address m 24.
LL above, also submit a copy of this form within 30 daA of eumoktt01r tit'%veil
12.Well construction method: nTQ�ff construction to the following.
it a auger•rotary.cable.direct push,ere.) Divisiort of Water Quality.Lloderaround Injection(control Prca.ram,
13.FOR WATER SVPPLV WELLS OigLY: 1636 Mail Service Center,Raleigh,NIC 27699-1636
i Method of test: t r 24c,For Witter Sann�&C,rotberatal Vlrelis: In addition to shading the farm to
13a.)'lcw(e,'pm) — the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C o''t Amount, completion of well construction to the county health department of the county
I where Constructed.
Form Gw-t \etth Carolina Depatnneat of Environment tuff lvv=)Resouwcs-Division of Weer Quality Rentsed Jar.2lt i 3