GW1-2022-08094_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD a
This form can be used for sin_le or multiple wells
1.Well Contractor Information:
�yf n
ohir 1 S 1tA.J�Y o QCt)Q M WA'7ER•Zti*tES
PROM TO DFSCR1PTt0\ '
Wall Contractor\ante
ft. ft.
NC'Well Contractor Certification Number34.OUTER CASiItFG far misiti.etsed webs DR LINER !f a
FROK TO DIAMETER s THIFIctiESS MATERLiL ,,1.
I ! ft. CD 114 'i
-- a4 V
Company Kam: 3b.IBtAiER 6ASIA G OR TiT tbermN'elnsed-loc
'. I FROM' TO DL?4rrER TRtCKtiESS ►tATERIAL I
2.Well Construction Permit M SW —034e ft. ft. m j
I'm/all apphovhla sell crruatructian permits lix.(ounry,Store,Nartauce.etc./ ft
3.Well Use(cheek well use): 37.SCREEN
Water Supply Well: FROM TO DiAMETEn SLOB 512E THtCK�}FSS MATERtAt
ft. Ft.
OAgricultural i3A�unictpal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
01ndustraliCommerciai 0Residential Water Supply(shared) 3&GROUT
FROM TO :1tATFRiAL E31PLACE1M&11rMEiROD&A.N0C:1T
,^.Irrigation fr•
Nou-Water Supply Well:
fr, tc.
10morsitoring ❑Recover'
Injection Well: ft, ft. 1
MAquifer Recharge 00roundwater Remediation 19.MI!D1GRAVEL PACT; if ieabFe
QAgtatar Storage and Recovery OSalinity Earner FROrs ft G TO M.iTERfAL E�tAS,irEMExrstert[oD
0Aquifer Test OStonmvater Drainage ft. ft.
GEaperwnental Technology OSubsidence Control 20.DRILLI YG LOG artaccb additioanl slicers if necessary
"-Geothermal(Closed Loop) OTincer CaD.l4 TO DESCRIPTIO\ eoter.hanit ess.soW.k r.-rainrue,erc.l
CGcothermal(Heatin=Cooltn Return) GOther(explain under 421 Remarks) fc fr.
fa fL
4.Date Welt(s)Completed: fs, ft.
i.Well Location: ft.
1? ft. to
F=114g.0 tte,Mair -•+--~,r J Pacilip•1D=ofapplicab I ft. ff.
�(o Btu la
fr. ft.
PPI Address.Ctq,and 21.REMARKS
Count%. I Parcel ideruitieatiot No (PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(i"well field,one lationg is suf view)
JV
Sigrraftue ofCmifted%Veil Contractor 4e
6.Is(are)the w'e11(s): aCrrnanent or ❑Temporary dy signing this farm./hereby cernly that the wel/fi)nag'6"01cy rmistrotirrl Incsccrin/anm
wuh i9A h'l'At•01C,0100 nr Ind MCAT'rtx' fl?0u 1Fri!C'ruxtrrtclnut,Uourinnli retd Ihur u
i.is this a repair to an existing well: Dyes or 9<0 cups of this recwid hoe bean pitwided to die weft ms•uer.
/l dim n u reparn ill alit karnen well ewla'irmcntw tnfrtrmation and capluin tire numre nil Ike
repair rtru/rr-.21 rem,,Ar.serftan or at the hock of ilrii.lnrm. 23.Site diagram Or additional well details:
You may use the back ot'this page to provide additional t4n11 siw details or"veil
8.Number of wells constructed: construction details You may also attach additional pacts if necessary
1•itr Je w nudes l rc trrn rtr rrrui•ia»c•r.a /c a ells OIYl F'u•dF,the-fame crltutruefiek yas curer �_ ' '�.-y • ^' 1
p v'p' 24.Submittal Instructions:
,uhmrt rate hunt
9.Total well depth below land surface: @05 {ft.) 24a. For Ali Wells- Submit this form within 30 days al'completion of we
(��
hi+rmtdNlile xe!'shslall depths d dillerewferample.3@200'agt!?r1001 construction to the following. _C) �`
_ _ _ _ - ------ - -- — : -
lQ.Stark water love!below top of easing: 1 -4 y (ft.) Division of Water Quality,Information Processing Unit, .�n Pf C1- �Ur.+i
it a suer,/t•tr/t,uhr+rr c u.,ur},rr.,.•"II"
1617 Mail Service Center,Raleigh, C 27699?tit" i
11.Borehole diameter: l[i i (in.) 24b.For Inieetioa Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion, of tvcH
12.Well construction method: � QY construction to the following.
it a auger,row y.cabte.ducat push,etc.)
Division of Water Quality,Underground injection Control Program,
33,FOR RATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276".1636
I [ 1 24c.For Water Saanly&Geothermal dltelts: In addition to sendtn�the form to
13a.1'ield Method of test:� lbv., )
(`ePm') the address(es) above, also Submit one copy of this form within 30 days of
13b.Disinfection type: hl�rs - Amount:_ completion of w y
well construction to the county health department of the count
I where constructed.
Forn,Caw-1 North Carolina Department of Environmem and Natural Resotu:es-Division of water Quality kc%ised ho 2013