GW1-2022-07254_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORD F i
This form can be used for single or multiple wells "
1.Well Contractor IInformation-
f 1 S tt�.J h y_ re e—nQ, 14•WA7£R•ZO�tES
FROM TO DFSCRIPTIO\ �
Well Contractor Name Et fr i
ft. j
Vic'Well Comtactar Cectifieation Ktsmbcr IS.OUTER CASH for taisiti-ersed webs R LINER rf a
ppRoMe
FROM TO DUmrrER r THIOLNESS MATt9tIAL
21 11�1111 te1G p ft. 5 fr. . t ._ a t1 PVC
Compam!�mn_ }/tea f.I F
ROM
CASIty;OR tkerlaal HICIdrioe /
r lJ W(� Ot��� � ft. D�METER Ti[IGK.\FSS MATERIAL 1
2.Well Construction Permit M_� n' f
l.+.0 all opph'evhlr sell cuuslructian penaits fi.e.C'ounn•,State,1'ariaacr.el:./
3.Well Llse(cheek well use): N
Water Supply R'e)L TO OtAhtETEM •'LOTs12E THiCK�FESS MATERIAL
ft.MAgriculturaf _IOCreothermal(lteating/Cooling Supply) esidential Water Supply(single)OlndustrtafiCammerctzi t7Residenual Wager Supply(shared) To atAT£R1AL E.iPLAC£MM-tMETHOD m Aato
1 Non-Water Supply Well: rc. ft.
�O'vlonisoring GRecaven•
Injection Well:
OAqutfer Recharge ❑Groundwater Remediatwn 19..%ID/GRAVEL.PACK fif awlicablef
FROM I TO MATERIAL £MPL►CEM£.Yr31MIOD it
C lAquiter Storage and Recovery DSalinity Barrier h n,
r
ClAquiler Test ❑Stoamvater Drainage ft. ft.
CExperantental Technology Subsidence Control 20.DRILLING LOG tartzmeh additional sbeeta ifn=esssry
coeotl crmal(Closed Loop) OTracer CIIDat TO DESCRIPTtO\ talorhardaest soiYrock r,-ninsu,erc.1
CGcoihcrntal(Acatine Cooling Return) OOther(explain under 021 Remarks) J
£a Ea
it. it.
3.Date Welt(s)Completed: fs, ft. I'
S.Well Location: fr. t. r;�"1r,,r 9 E• I
ft. fr. 1
i�aaiit).ihuic:�mne Pa;alin•1D-rifapplieable) ft. ft. r 7
J.
(� ft. ft t. rpi;'c►t!Drt Prcc
Pi t sical ddress.Cn),and Z'p 21.REMARKS' �' a
toI ,
C'ountt. Parcel ldetuitit:atioilNo(PIN)
5b.Latitude and Longftudc in degrees/minutes/seconds or decimai degrees: 22,Certification: !
(ifaell field,uric latloog is suffciew) 1
Signature of Ccnified Nell Contractor +e
6.Is(are)the well($): SKrtaaaent or OTemporary fly,slplll)lg lhis,form,I hrrrh}•ceri4 that the wel!(.y"as(Item rnrtstruclyd ra accrentancr
nv11i/9A NC'A('U?t'.O JOU a /SA tiC'A['nii 'Opla C}ow l"trucieni laarhints and llral o
J.15 this a repair to an existing well: ❑yes or 440 cv+pv aJ ilim rrenrd has her",
prrrvided In The u•efl ox•ner.
/J dim i'to repmr,fift nul kturire well ex iumucnrul inf irrnaliiin anti trl;4IM life uamre elf Ike '
23.Site diagram or additional wei)desalts:
retuirr nru/tr ?I nrMariCr xeelian fir ai Illy hack ujdils loon. i.
You may use the back of'this page to provide additionsl well snc detail,or\\'rail'
$.Number of wells constructed: construction detsils You may also attach additional pages if necessary
I•br miduple uilrrur:n ur nun•natcrstyilrlr t+alh ON.t•1171F,the samr crntsrructfait,you ran
ahnultnvJruat 24.Submittal instructions:
n
9.Total well depth below land surface: J {ft.) 24a. For All Welts: 'Submit this firth within 30 days at'completion of+\ell
l-nr aadulde n e1Aho all depth..if dillerwil fenuap/e•-3g)MY and?/ii/fill') construction to the following
10.Static water level below top of easing: (ft,) Division of Water Quality;Information Processing Unit,
!1++ut,-r h•:rt t.a>wrrr<ri.,,a1;,n.,,-••,,00• 1617,Iail Service C.eeter,Ratt:igh,NC 27699-1617
11.Borehole diameter: L I3 (in.) 24b.Ivor Irilie-Ction`W11si -In add itiofl-to sending-the i'orm-to-the address in-24a
above, also submit a copy of this form within 30 days of conlDJetiat. ut•+veil
12.Well construction method: �inQ�'U construction to the following. ;
it t auger,min,.csbte.direst prat,,cit.) Division of Water Quality,[;ndetground Injection(:antra!Program,
13.FOR RATER SLrPPI.Y WELLS ONLY! 1636 Mail Service Center,Raleigh,NC 276"-1636
i I t 24c.For Water Suoniv&Geot rmal_Wells. In addition to scadm.-the farm to
13a.field �4mhod of test: V
(e'Pm) the addsess(ts) above, also Submit our copy of this form wnhtn 30 days of
l i3b.Disinfection to �1�t31'tI'1C_ Amount _ AQ
completion of+veil construction to the county health department of the county
Ix where constructed.
Form G+\'-t '`anh Carotins Depunment o£Euviranment and Natws)Rescutces-Di.•uton of%Vwer Quality. Recrsed jai:2013
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