GW1-2022-09169_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD
Tins form can W crud for single or multiple welts
i
),Nven CuntraccttoT inffoo ma�tion:
ttA.JEt3L1! eQ�C 14 WA RZty*t&S
FROM I TO DFSCRIPTJO\
ft. ft.
Well Contractor\Zalc
C9 136- A - ft. Ft.
35.dI1T£R tfor wr8s R L3NER a
\C'Weil ComactarCertification Number 1�ON TO Duet ESS MATERIAL I'
C'ompam•Vic:-e � rt y � .]6-INNER Ct1S[kG dR TiitCte�•FSs 1SATERt G :
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FN JJ�a.g g FRaM ft. ft D
2. t}l Coastra"lou Permit#: — i
l.r.<r MI arrr{icrrht�veil tnusmxnttn prrn,irs hoe.t'oonry,Srnrr,!'orroncr.etc./ ft,
3.Well Ilse(check well toe): i7.SCREEN
Water Supply Well: FROM TO DIAlttETER SLOT StZ> THICK SS �tATEa1tL
WGIR
in.
CAgriculturai Cmuoictpal/Public in.
demtal Water Su ) sin lef`0t;xothermal(i?eatinsfCootinz Supply) pQ Y( & } .MIndustrialiCominerclal CResidentlal Water Supply(shared) 0. TO �t tAL T, Frf uA MOt:\TCJt� h'
j Nov-Water Supply\Fell: to te.
}i7ytonitottng CRecovM
ft• ft i
j Injection Well:
uAqutfer Recharpx --Groundwater Remediation 34..SAA(D/GRAVEL.PACk if e
FRO rt TO ►rATERGt E�7t+ EYf St FI D
-Aquifer Stoner and RdCOYory OSalinhy Barrier h, fro
i �Acuifrr"lest uStotmwawrDrainage
CEapen+rentalTwhnolugy OSubsidence Control 7ADRILLI*1GLOG araehaddidonatsheetsiftt�r't
zGeothermai(Closed Loop) OTroeer To D CRtPttO\roter,ltaednus sot7hocft nine etc
i CGccth C
ermal 1?cattn ooltna Return) GOther lain under 421 Remarks) Fa fa
Ft FL
3,Date K'elt(s)Completed: I fs. ft.
tJ
5.Well Loco6on: ft. h•
1 ff. tt. S F P 3 2�.
acili hv+e:\a+nc (if applicable) ft. ft.
Jn
In I Sc.�rxns err Ft. ft.fit
?itysical Address.C d Zip JIt.REMARI{S
-Polk. rP 130-5o
C'onru. Parcel tdcluil:cutioll o(PIN
5b.Latitude and Longitude in degrees/minntes/seconds or dermal degrees: 22,Certification:
(swell field,vile tatlong:s suffietew)
1,0011
S+„asatttre ofCcn'Bed Well Contractor Dad
6.is(are)the weii(3): 21petmaaent or OTemporary yy alai n»g lhts•forin,/herrhy cerh&that die welffij Her(here/rn+rr Oetl11)atsrmlaticr
1 N'1rh 15A NC'AC'112r'.u10u nr 15A X'A( 02r' 0It/11 lt$il t bntt►rx ma,Crnnrlrtrtl,and Ilan tr
7.Is this a repair to an existing well: Dyes or' V No wipe uJ ihu net»rd hoot been prrtvfded lei Me ark tiwner.•
tl iron to to rrttart:,I+l1 nrrJ ktntaw wdl ixamfearntw w Jormanan dad t•,eplaiN the avinfe ell the 13: diagram diagtK or additional well details:
retwir tinder:41 mono rkv.vmffan ar w the hack of 14h Arm. - '
! you may use the back of this page to QfOVIdC addttlorta!tNell IISC details t7r UYII
R.Number of wells constructed: construction details You MY also attach additional pages if necessary
r:
/•:+r nudtgJe nttrtvrvl ar tial-n•dti•r.re,pplc uelJr 0M..P a'IIh the some edntlr c&n,►Y;11 rm; 24.SahmittaI InStraCNOAS:
,uhnut ring hlrtn �
9.Total we)i depth below land surface: Jos {ft.) 24a• For An W iis: Submit this form within 30 days of compleuen :if ttefl
Vor n;nhtive it eAr host all drfah.,it dtllerent(eximytle•322111)'Owl 2{d/lift) construction to the fallowing
.,Division of Water.Qaality,Information Processing Unit,
tQ.Slat)cxaterlevel;beloW.ttrpofCaSits�: � —(�)` StiI7VlailSeaviceC.trrtter RRleigl vC2'96�9=iE15
lh�a,rri::a•1r�ulwnrta.•ur}.trap.. .• ` i .
I 24b. For i iection Wells: In addition to sending the form to the address to 24:
11.Borehole diameter. (to.)
above, also submit a copy of this form vithm 30 days of cumoktto:: of well
12.Well construction method: gntar construction to the following.
(+a auger.rota•.cable.dirc:t push,etc.) Division of Rater Quality.U'nder;round Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276".1636
13.FOR%vATER SVPPLY WELLS ONLY:
130.Vield M Method of test
9:J
24c.6e+Water SnDsrIv sit C- he:mal'Nte!(s: In addition to sending the form to
(,•ptu} the address(a)above, also submit our copy of this form wnhin 30 days of
C�1�01'IY1F Amount-_ elf completion of well construction to the county With depattm�n o4 the coumt
13b.Disinfection type: where constructed.
' t2Ctt5ed lsr. 2013
Fom+titV-t Carolina Department of Environment and Natural Res a ovea-Division of Water Quality