GW1-2022-07255_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD F
This form can be used for single or multiple wells
1.Well Contractor
,Information: n
54.
1[�Jr ULfQCI�� --WATER'ZWE5
FROM TO DFSCRttrri0\;
Well CCont1mucir\aloe
�C'Wtll Contractor Certification\timber -is.—OUTER CASIIYC+ for misl0•msed wells R I.IIIER :f a �'
FROM I To D NATERiAL ,
I ft: fr.
Comparty Koine 16.1NNER 6ASIivG OR im1'elaxd^tao
c ^^ FROM TOD1AM1tl•'rEA TfitCKNtSS MATERIAL �
2.Well Construction Pet met#: v Wd d �U P ft. ft. 1'
Lt,i nAa cnhlr xcH cvrustrrxtirut ,milts fr.e.(bane',5tatr,Noriaicr.rlr./
Aldr a ft. ft.
3.Well list(check well use):. 17.SCREEN
Water Supply Welk FROM ITO DUMMIC 1•5LOTSI2E TIitCK�FFSS MATERIAL
ft. in,ft
CAgricultural i7A4unicipa}/Public '
OGeothermal(Feating/Cooiing Supply) residential Water Supply(single)
ft. ft.
10litdustrialiCommerciai aResidential Water Supply(shared) 18 GROUT
FROM TO MATERIAL Ea1PLAC£MEN117METROD 6 AMOUNT
Clrrigation
i Nou-Water Supply�t'ell:
r
j 13Moaitoring GRecovM,
(Injection Well:
!uAquifer Recharge OGroundwater Rcmediation 19..SANDJGRAVEL.PACR if ieableit
FROM TO MATEttLCL �• EMPLACEME.KMErttOD
!CAquifer Storage and Recovery OSalinity Barrier
!::,Aquifer Test uStonnwater Draina_e
QExperkitental Technology OSubsidence Control 2p,DRILLING LOG attaeb additional streets if acrseaev
00eothefmal(Closed Loop) OTracer FnDM TO DESCRIP•i70\ color.limciz sr.saYroek e.•ninsire.eu.l
CGeotliernial(HeattnCo� olingCR'etturn) 4OOther(explain under 921 Remarks) ft f`
1r 01U- �� ft. ft.
4.Date Welt(s)Compacted: ft, ft. or.�,
.-I.Well Location: tc. t. a
�,ohb Gall ft. fr. AUr
i�cedit).fhum:\acne irwalit?•1D-pfapplicab}a) ft. ft. -
IqU Farah Ai11 Drive ft. fL DW /
Physical Address.Cn),and Zip
21.REMAR1iS'
�
C'uuato Parcel identifeation No(PIN)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification:
(t:'aell field,une i itlong is suf&sem)
— S)gre+ure ofCcnified 1VeIl CantraNar Bate
6.Is(are)the well(s): twermanent or OTemporary gy signing ihi.s faro,l hrrrhj-cor,0 that+lid Ive116i/14Af 61ere)via ivlroortI ai iavordaicv
x•nh 19A:YC'A('n21'.0106 ar 13A tit*AC o-% 'myll)li'e1J t rmrtruciuui.GanrLrrrJ.t and/ha a
7.is this a repair to an existing well: Dyes or erupt q/MAY reenrd has horn provided tit the xrll ax•aer.
/i rill,t.,to reliara ill nut ktunvu well eraeviruaaitt onforinathin and cap/a/u the agave 4 the
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repair+inter::2/remrkc.,delta or at the hark tiif itth fora. 23.Site diagram or additional well details:
You may use the back of this page to provide additional will site detail,or well V
8.Number of wells constructed: construction details You may else attach additional pages if necessary
1•ttr im ltrple intreru:n ar nna•n ale r..upp/t•cell,OM.)'x'ilh dir some 71av traer(at.jail reu
,uhniziundlarin 24.Submittal instructions:
9.Total will depth below land surface: {ft.) 24a. For AN Wells: Submit this firm within 30 days of completion of.well
Proraudnl+ld%I01AJlrrad ddprh.c itclillerent 1ecrutrph••3@201'alsl Ch 10 •) construction to the following
10.Static water level below top of casing: 1 (ft.) Division of Water Quality;Information Processing Unit,
//vua-rh•d/r.ahrnrurauil,aa• /" ^1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter: Ili 1 (in.) 24b.For Injection Wills'. In addition to sending the form to the address:n 243 `
above, also submit a copy of this torm'within 30 days of completion of wrll
12.Well construction method: tsQi�l! construction to+lic following.
!t c su er,rotary.csblc.dir"I push,etc.) Division of Water Quality,Uflderground Injecdon Control Program,
13.FOR RATER Si+PPI.1'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
l 13a.1 Yield Method of test es i J 24c.Par Water Suonly&Geothermal Millis, In addition to wading the form iii
(e'pm) q/}O n the address(es) above, also submit one copy of this form within 30 days of
! )3b.Disinfection type: Chlflrt Amount d completion of well construction to the county health department of the count\
where constructed.
itavistd jar.2013
FormGi,V-i North Carolina Department of environmem and:Yams)Rescur:rs-Division of Weer Quality,
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