GW1-2022-08093_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD s
This form can be used for siaele or multiple welt$
I.weli contractor Injf�orma�tion: n{f1,5rtlLiQCJ� 3.wa>ERza*tEs
FROM I TO t)FRCRtPTtO\ �
Well Contractor Natre
01 - ft. ft.
NC Well Contractor Cenifieation\umber 15.OUTER CASiNG tfor mef0-eased weft L►R LINER a
FROM TO DIA I T81Qt'F!S MATERLl1 ,J.
a�
Company Naini 11 ..16.INNER 'G OR ars3'
+ �H �at q I q FROM TO DL►MLgM TfitCK.\'t5S MATERIAL
2.�i ell Construction Permit#: ft. ft.
1
l,r.,t all apph'cah/r%ell enusiructiun permits(i.e.('Dunn•,State,lrar'tonea.err•/ ft, _ ft.
3.Well Use(check well toe): 17.SCREEN
15'ater Supply Well: MOW TO DUatETER 5lAT SMME T1itcK�FLSS ►SATERtAL
ft. ft. in
OAgricultural f3i\4uaicipai/Public
� fr, tr. in.
OGeothermal(Featin Coolin Supply) Waxer SuPP1Y(single) I
.
0lndustnaliCommerciai L0Residential Water Supply(shared) PRO—M IiT
FROM TO MATFRUL I EarPLaC£MLKI'METROD&AMOUNT
!-irrigation I ac'ft.
Non-Water Supply Weil:i it. ft.
i 0monitoring GRet:overy
Injection Weu: ft. ft. I
MAquifer Recharge Maroundwater Rcmediation .19..SAND/GIRAVELPACK af
FROM TO MATERIAL I rt?tP t_vrmrr1lOD
DAgtufer Storage and Recovery OSahnity Barrier h, n
JAquifer Test Mormwater Drainage
i A. ft.
oEaperimental Technology DSubsidence Control 20.DRILLING Lt3G attach additfoonl s6eea irue,=Ssaml
jCie.theemiii(Closed Loop) DTroeer FROM To DESCxIPt7o� eelonhadnett saiYnoehr ,-eain Sim etc.)
CGcothermai(Heatmg Coohn Return) GOther(explain under 921 Remarks) fa fa
i A_ ft. fr
4.Date Well(s)Completed: ,Cq Ln I•� 1 ft. ft,
5.Well Location,:
i--rli N.;au:t Facilin•1D=trfapplieable) ft. fs.
p 1
�1 t AJ _ _ 14W ft. f).
Pipsical Address.CV11464d Zip 21.RE,'19ARhS
-R01, 13a-50
C ounu• Parcel IdelaNeatial No(Pl`)
5b.Latitude and Longitude in degrees/rafnuteslseeouds or dceinrsl degrees: 22•Certification:
(d'wdl field,one lailong is sufficient)
Si_amture arcerti ad%V411 Contractor Dat,
6.Is(are)the ee11(s): l6ermaneat or Memporary Ny.sigomrg ihis firm.l hereby nerdy that the u'el/f,�non'Ar'enJ rwtstruitatl mt mc'r/n/wrcr
ai'ulr 13R.,Yi'aC'mM'.U/0m m•15d NVAC ON' m 2mt1 Igei/C'uncuuclmrl.Gaurinrdt and thul a
i.Is this a repair to an existing waif: Dyes or I/NQ cup♦e�thcs recnrd haR lwau pPnvidcrJ to rho is r/!ua'rrer.
It riu.,la to repaot fill airs kurmn wd/errrulnKnew rofe/rwamwa and tsplain the nal/ere et/Ihr
reivir under..21 remrks.sermon or a+11w back 40/f/s harm. 23.Site diagram or additional well details:
( You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: d construction details You may also attach additional pries if neetsskaaN ry
Far nudmplr wiremal ur nwr•trolc•rsry+plr•a ells 0M..I'u•IIh file 8atae raitrlrmeXnlJ,}Ylr/rail V F' 1,� ea`y;---
uhnul rn v Jnrrr 24.Submittal Instructions: 6-.t g,o,, ..
9.Total well depth betow land surface. 305 (ft.) 24a. For AN Wells; Submit this flint within 34 dais a!'cnmpleuyp(�f'1 e 2022
l•irra+ulmislru.•lhlrsrai/depth..rldrllerduferwrtple••3• ?rXl'aeul?lei11041) _ Construction to ilia feHowin3_ ff-i1 _ 4 _ L _
' 10.Static aster level below top of coaling: ��, ({t,) Division of Water Quality,laformstion Processing Tjtrzirr�'C� Fi�:;3G��ng UrK
10.Static
t c a e r le Man�el w 1617 Mail Service Center,Raleigh,;NC 27699-1617 U911Qi30G
11.Borehole diameter. (in.)
�(} ) 24b. For Inieetion Wens: In addition to sending the form to the address in 242
above, also submit a copy of this form within 34 days of completion of wr1!
12.Well construction method: �}n�QY� construction to the following.
tie nuj;er,row y.cab:e.dams push.etc.) Division of Water Quality.Underground Injection Control Program,
(I3.FOR 1ti'ATER SF'PPI.!'WELLS O!4LY: 1636 Mail Service Center,Raleigh,NC 276"-1636
�r Ala ! 24c,For Water Sanniv&(,eatkermal VI'aits: In addttron to sending the form to
13a.1'icld(b�pta) Method of test: t}te address(es) above, also submit one copy of this from �vnhin 30 days of
i3b.DisiDfeetiaa type: l !'itsJ'!t!'1C_ Arttouat _ completion of well construction to the county health department of the count♦•
I where constructed.
Form CPtt••-t \anh Carolina Depmwwnt of Environment and tvauml Reso=cs—Division of Water Quality xe�ise3 Jan 2i1 t 3