GW1-2022-06804_Well Construction - GW1_20220715

1 I/Lt1,1 YI I Ii
W—Eu CONSTRUCTION RECORD LCM- -11 For Tutemd Use On . i
1.Wen Contractor Mormation:
jo V
P©ill:' 1 .WATER ztnvs
WellCatlCactCr Natgo�_ FROM TO i nON
%
NC Well Coattaetor Cerawon Namber j� iS,0 Va OR LII4ER f..
n p LAV FROM TO D1A61L� M 7ffiC1tIiF86= MATEMAL
!i C ll..
CamparryName
Ili. #>Rt�Nti nlosed.loo :.
2,'Wen Construction Permlt#: FROM ro DrA rnrctas MATERrAL
List all oppL'cabie-well conswaefionpermtfs j%a UDC,Connnt State,Variance arc) �• R t°'
3.Well Use(checltwen use):
Water Supply.Well., 17.SCREM'
FROM TO DIA6nm I SIMSIZE I IrMCKN=I I-MATMAL
Agricultural 13Municipalftblia ft, la
Geothermal(HeatinglCooling apply) 13Itesldentlel Water Supply(single) ft• fL �.
htdnstdaUCommeneisi DResidartial Water Supply(abated) MGROIDT.
Irri ti MM TO UNT
Non Water Supply Went ft. ® it. IdAft
Monitoring Oftecovery1t. fT,
ection
lawthem
gniferRechsrge OGroundwater ltemediation
quifer Storage and Recovery dy Salm Barrier 19.SANiDtC;irA�lEl,i'At:rt f cable
1, FROM TO ATERiAL 1 I EI1tPLA METHOD
quifer Test O9tormwater Drainage It. ft. }
xperiunental Technology 133nbsidence Control tt, tt: I >„�
eothermal(Closed Loop) QTMW M .L+OG h Milner sheer.u
al ea' Cop Retur thher n under#2l Remarks iROM TO DM iPfrON br eoNYoek ct�
4.Dateell(s)Completed: _ "a Well ID# ®(j'W
SQ.Well Location:
Facilitq/Oamer Name Feai&y ID#Cf'appllcablc) ft. tw T,— ,l a
ft iml Mass,Cny w d z;p 'T' rt. n• J U L 1 2022
a 0;�( 5 31 O 1.2oX zt.
Coi4 parcel ldendtieatim No.(PIIdj v}
5b.Latitude and lonotude in del reestmdnntalseconds or decimal degrees: d;UFM' ,M JI I i
(if Well field,ono la!/lang fa sufllctont) 27.Catt@catlon:
N W
6.L(are)the weil(s)dtermaneut or Temporary sigtlatitn of ' ed well Cor4ador Date
By signing ift fornb I hereby ceptpyr ihx'da isvil(s)was(Were constructed in accordm w
7.Is this a repair to an existing well: E3Yes or d1io with I9A NCAC 02C.0100 or ISA NCAC 02C.0200 well Constracdon&wdernb and dar a
.{fumes is a repair,fill out known well COM&Wdwt i lformadon mad explain the natwe q(the copy q/7hls record has been provided to the wdl owner.
rqw-r under421 remarks section or an die back of thtc fim.
2&Site diagram or additional well details:
8.For GeoprobefDPT or Close&Loop Geothermal Wells having the same You may use the back of this page to provide additional well site deWls or well
construction,only-l-OW 1-is needed. indicate T+OTAL-NCiMM of welts construction details. You may also attach additional paged if necessary.
drilled:_i � �AL INSTIZIICTIONS
9.Total well depth below land surface: ® 24a.Fur Ari wear: Submit this form within 30 da` of
For muU(ple wells ilat all depfin(fdVe►•eat(example-9Q200'and 2@100g ys completion of well
constriction to the following; 1,
Ia.$Stae water level below top of casing: 20 (ft) Division of Water Resources,information ftocessing UM4
jfwatcr level is above cadn&use"+" 1617 Mall Service Center,Raleigh,NC 276W1617
11.Borehole diameter': on) 24b.FpX inleW2n Wd�r In addit onto sending the form to the address in 7Aa
12.Well tonstrucolou method: lt"n yam_ above,also submit one copy of this;four within 30 days of completion of well
(La auger,mmry,cable,direct push,etc.) construction to rho following:
Division of Water Resources,Uudergmmil lNectlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Meg Service Cei er,RM04 NC 27699-1636
13a.Yield(gpnt) Method of test: 6 6J 24c.For Water Snaniv Bc Tniectlos Wells: In.addition to sending the form to
1+ the addresses)•above, also submit'one copy of this form within 30 days of
13b.Disiafeetiontype: Amount: �i.l completion of well construction to;the county health department of the county
Where constructed