GW1-2022-09168_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD
This form can be cued for single or multiple wells
1.Well Cuotr2cloor IIn�formaltion: n to
Y 1 S rt�.J I LIZXe C f t� 14.WATER ZONES l
FROM TO DESGRIPTIOK
Nell C'untracror Name nn ft. fe,
(� � �S• fT r,. rt. j
N('Well C oitvactar Certification Number 75.OtJTER CASING !aa(0-cased we1Lt DR LINER :f a
FRa f To auMETER Tg7CKYEss MATERIAL ,r
1 rt. �. i.' 4 v '
Compan Name FROM
INNER CAS___ OR tbariin3 d .din
_ Q FROM Teo auneerER TRrctc.��ss MATERIAL t
2.Well Construction Permit#: C� ft.
Led all opocahle well maxrructiun permits fix.f'aunn',Stare,Norraaee.etc./ ft ft
3.Well Use(clink well use): 27.SCRBEN
Water Supply Well; FROM TO D1AhtETER SLOTSIZE THICV-4EAS MATERIAL
PP} ft. ft. in.
--Agricultural --Niunicips)/Public
OCreothennal(Heating/Cooling Cooling Supply) sidenual Water Supply single ft.
(• � � PP53 +� PPY( 3 .
--lndustrialiCommerciai 0Residential Water Supply(shared) t&GROUT
FROM I TO MATEttLAL ErtiPLACEMt:TT METHOD 6 AMOt'\7
Clrrtaanun fr' aG'fs r�i�x Y
i Nazi-Water Supply Wool: re. ft. -
I❑lAonitoring C.Recotim ft. fL
Injection Well:
uAquifer Recharge --Groundwater Remediation ROM 79..SANDIGRAVEL PACK if ieable
E�tPLACEMf.Yr�lETFIOD
CAgwfrr storage and Recover --Salinity Ban F TO MATERIAL
ter tr. n•
❑Aquifu'fcst UStonmvater Drainase
ft. ft.
GExpera:tental Technology --Subsidence Control 20•DRILLING LOG artsob additional sbeetc ifnrrasarr
1:Gcothermal(Closed Loop) --Tracer firab! TO DES[RIP1)70N eWer,bardaess.soill—k e.•r+ie+sise.ere.
1 CGcothcrmal(Heating Cooline Return) COther(explain under 421 Remarks) ft. ft
ft. fr-
o.Date Welt(s)Completed; f ft.
5.Well Location:
� e� FcnrnmS ft. ft.
1 aeilim(h•tie:Name I:a:ality t0-(if applicable)
ft. ft. Inf 'I nil
1029 Dtua= Fit Lane,- U-iL ft. rt..l_ rims
Physical Address.Ctt),kWd Zip 21,REMARKS
PetL P(Dg-S
Comm. Parcel Idcruitication No(PIN)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification:
(tf nett yield,mu lac long a suffieieisl
�/ Sigttalure of CcniSed Weil Contractor is
6.Is(are)the w'ell(s): tldPennanent or --Temporary yy,rip»rug ihu,jarm,l hrrehy carl!fy that the wellfy xcu'(seen)rt"011`09ird»r atrrmluncc
Wah tiA Nt'A('t4C.0IOU nr 15.4 N(*AC U?C' O?At/lYeil C haute ctnut.6nnrl rnit unrl tlxrt a
7.is this a repair to an existing well• Oyes or 1240 cvpt cif that reemrd hair hers&(aided In the Well nWner.
it clam m a repair,fill nut krurae well mweiticnorr mformanrm and exPlahr the aurae ril the .
repair neuter,21 rrmarkv xecnnn or ai flu•lark of rhix form. 23.Site diagram or additional well details:
You may use the back of this Page to Provide additional well site details cir well
8.Number of wells constructed: construction details You may also attach additional pales if necessary
I.S,r usidople rnlra mar air nun•t+'a»c r.,npplt a ells ONi.Y W»h,the some Cwrxtrurttat,ymr Cott
,uhmaanelnrai 24.Submittal instructions:
9.Total well depth below land surface: {ft,) 24a. For Aft %fells: Submit this firm within 30 days of completion of%tell
l nr a;ahy+le a alvhrl vil depth.,it rGl/ereut fean»pir•3•^g2t;V aiul2 to/fief) Construcition to the following
t ,
10.Static water level below top of easing: LAD/ (ft.) Division of Water Quality,tafarmation Processing Unit,-- - -- .. - 1617 Mail Service Center,-Raleigh,-tC_27699-Ibi9 - -
!h:urrr!..vt r,uhn•r ua.w}.aa•..//aa ------
11.Borehole diacteter: III I (in.) 24b. For InitStion Netts: In addition to sending the torm to the address in 2J:
},
above, also submit a copy of this form within 30 days of cumpirtton of%veil
12.Well construction method: An far 1I construction to[tic following.
it a au,�er,rwitry.cable.dira:t push,etc.)
Dn•ision of Rater QnRlity.Underground Injection Control Program,
13.FOR`.WATER SUPPLY WELLS ONLV: 1636 Mail Service Center,Raleigh,NC 276".1636
I i I 24c.ForFor Wate�St}�tly&Geothermal Wells: In addition to sending the form to
13a.)'iei(t Method of test: e _
(e'Pm) I � the address(es) above, also submit one copy of this farm wnhm 30 days of
13b.Disinfection type: ou 1r Amount•. _v completion of well construction to the county health department of the county,
where constructed.
Fomu G%Y-t Nnnh Caratina Department of Environment and Natural Resources-Dia•esion of water Quality Reused tan 2013