GW1-2022-07923_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD f
This form can be used for sinSIC or mutripte wells•
1.wen Contractor Infform-ation:
oh,(]S hLl G�eQfrly FROM
BRZ01�'ES i
10 DESCRiPTiOV I �
\vela Contractor Name ft. fa j
no ;
SFR5 At3�4t]!ER ae� tt�a MTNt'Well CcactorCeniftcuionN1mter To ERiA1 1I
'
Compam Kane 16.4itNER OR
• FROM TO I D1AM TNIt KVt MATERtAL i
2.Well Construction Permit#: it. ft.
1.,.,t all appb'cahlr well crrurfraerhrn permim(r.c.C•ounri-,State.Yarlonc..ere./
ft. R.
3.Well Use(cheek well use): 17�REgK
Water Supply Well: ['Rt3?ti T DiAhfETER S[ATSRE THtt:tC.VtSS MATFRtAL
fs. fr. iTM
DASricultural uoicipal/public
ON.
Fi OGeothennal' aling/Cooling Supply} esidettual Water Supply(single) .
ft. fr. in•
�industna;iCoinmerctzi Residential Water Supply(shared) _&GRt?UT
17
i FROM to MA PLAC£ME.1T, t:TftOD6A.M Ot:\T
1^.l:ctlmtwr, ft. a� fa 1'X Y-
Kou-Water Supply Wall:
❑'vlonitortng CRecovery
j Injection Well: ' fL
uAquifer Recharge ❑Groundwater Rcmediation .19..SANDJGRAVEl PACK if e
FROM TO MATERIAL 51PL► t:VrMFrtioD
CAquiter Storage and ReCovey OSalinity Barrier fr n.
DAquifer-fcst uStormweter Drzinaet
QEaperimenial Technology oSubsidenee Control 2() DR1LL11YG LOG atsseh addidoaal aheept ifss nry
-Geothermai(Closed Loop) MTracer M TO 0ES[RIP770N got°r•eadaass°'ttreeh -rain s at.etc.)
i CGenthcrmal 11.eatm9 Cooling Return) COther(explain under 021 Remarks) ft fe
ft. ft.
3.Date Welt(s)Completed: ft. ft.
5.Well Location: fr. f1, 1
tnu)prs ft. ft.
rx+li Na;nc Facility IOM(if applicable)
t
i e-p CL, ft. f�
icai Address.Cm,and Zip 21.REMOh-S
C'o,,,t:g Parbel ideruitiemioti No (PIN)
,�. ws a
v 5b.Latitude and Loagftude is degrees/minutesisecouds or decimal degrees: 22.('ertiftcatiom A U r "d S' 2022
{;f nett sieid,o,u Istiong is sufCiesera)
Signature ofCcrtified%VeilContractor D'A"Q/30c- Date
6.is(are)the well(s): i6ermaaent or ❑Temporary yy,c/u,drag thrs•jnnn.I brtthy ecrllfy lhuf the:trcJ/C.y xa�'lsr'eny tturcrractrr!in utcr,ratuncr
will?15A NCRt'u2t'.UlOU nr/SA ht'AC'tj%t wou wedC in,an,clnur,Vnmk+nh and then u
7.is this a repair to an existing well: OYes; or 1�10 trips q/dw recrnd has here/rrnvided to the well iiwner.
if Ih,.,m rI repair fd1 ran.4nrm'N b ill adsunwnim w1rrmatton wed a pini„the.liner qJ the
repatr under..21 unlike.rectrn„or on the hack of fh/.t Ponn. 23.Site diagram or additional well details:
You may use the back or'this page to provide aJditiciml well site details or well'
8.Number of wells constructed: construction details You may also attach additional pages if necessary As
Ivr atduple wlectom,or Weds-n»lt r.ctyytic t+e1h ONI.1'wip Ike SQAre r4o t ella t.yin to; �Y
.uhn+el one lnral / 24.Submittal Instructions:
9.Total well depth below land surface: a �`� (ft.) Zia. For AN Welts: Submit this form within 30 days of completion of tell
1•ir11;utu1les,,,gv11xtAdepth..11eli/lerew(emnyrh•-9^g.NHI'oexl2g/tiff) construction to tile following
10.Statist aster level below top of casing: (ft.) Division of Water ce Center,
r,Rateig ion C 27699.1 Unit,
-- -TfS,u'L=r7,i'r7i.�,sre+r.�u,l::.s,••-• — —- - 1637�•IaH service Center Raleigh,NC 27699.1637
:1.Borehole diameter. (in.) 23b. For[aieetion JJ0: In addition!lo"sending the form to the address In2- --
NiJ
above, also submit a copy of this focal within 30 days or'cumolctioi: of well
12.Well construction method: �in#'Qr construction t0 911Q following.
a e ,user,rota'.cWt.dtrcct push,etc.) Division of Water Quality.Underground injection Control Program,
j 13.FOR%t'A I ER SErpPI.Y WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276WI636
13a.1'ieict elfnil4ethad of test l 24c.j:or water Sanely&Geoihesmat Hrells: In addition to sending the torte in
(e'Fm) rite addrages) above, also submit one copy of this form wnhin 30 days of
13b.Disinfection type: Amount _ completion of well construction to the county health department of the court
I where constructed.
Fom,GW*-1 Kanh Carolina Department of Environment and Natural Rescurus-Division orwacer Quality kc%ised jar.2011