GW1-2022-09241_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD atoll For Intelzlai Use Only:
I.%Nell Contractor Information:
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Nen contractorName ft, a 1 R.
NC Well CevtracioreettifiestionNumber i5 oM= (for wells)o2LIIi�(if )
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,t}p S�C. yjdgj / ic' ft.
Company Name / 16.1NMCASINGOB closed-1
2.Welt Canslruclion Permit�: G rl' of 31.Q �xaac To Auutt.�tt Teaclttvnss atnrsarAr.
tl.11 all applicable Well conswcdan peIMS 04 U1C,Cdeuty.Star+:,Parlance,etc.) Q R' f �' (p t�r 'D' SDI 21 JrC,
ft. ft, Ita.
3.Well Use(check well use):
17.8C8Si$1
Water Supply Well. �7C5idCUU7aI
esost To D1AMetelt sLo�stze Tmel rlEss M90 L
Agricultural C. ipt/Publieto-
a mthmnal(Hm inglCooling Supply) War Supply(stogie) it, fL In.
Industrid/Commemiat DResidential Water Supply(0=0 lg t'RtoUT
.IMERI1Q11 bROSi To MATERIAL I MACIMTMEMOD&AMOGNT
lYan Water Supply wen: ft' o�b •�� �-
Motdtorin Recovery R• R• e
Igtection Well: ft. s.
:)Aquifer Recharge DGroundWateritcatediafion SANNIlftiRAYBGPAt�i
[CGOW:1,
r Storage and Recovery Malinity Barrier t+ao3s To MAMMAL MOTAt�,1t�M MEMOD
rTcstStatmwatcrl?rainagt:
mcntat Technology ®fSubsidenee Control R• R•
mal(ClosedLoop) DTtacer F.RGNI TO lmal(Hca' Conlin Return} t3Ulcr ex lainunder#21Remad:s) ° DfSCRiPTION(oi>ar wn@adc
D �• �8 a. eta 6c2�
4.Date Wells)Compteted:(3 7,-a_1!hell W# ft- ?. e. ra nP
a, tt
So.Weli Location: fL
-
PacilitylOwner Name Facility 109(if applicable) R' c
Physical Addrea,CityTandZip
P5-- 1d5 ILBIUMAM
County Parcel IdenBficationNo.(PM
sb.LaUtude and longitude in dWeesiminute aconds or decimal degrees:
(itwell field,one latilong is sdficiem) 2'L,Cerdflcatfon:
3511 W p'a 211 0.10196 w_ - --� �,� 1 _a a
6.Is(are)the welf(s) t or Temporar�No
SjgnaOtir:ofCRtifial tivaA Pontragor Datc
BY sighing elilr jomr.r hereby—djy that the-0(s)nns fuaere)cwu[rocted in accordance
7.tsthis a repair to an existing wellt Yes or frith ISANCAC o2C AIW or ISANCAC 02C MW Welt Construction Standards and that a
tlthis is a repair.Jiff ant known iveil construct Ltfarmnttan and esplaia die naturr of the ropy tlf►his mcord hoe been prinided la the weft oumer.
repairunderg2l mnarkraertionaron.thebackofthisjomi. 23,611gdiagmmoraddidoO udwdldetailst
8,For GeoprobvIDPT or Closed-Loop Geollmann l Wefts having the name You may mm tiro back of this page to provide additional well site deraila or well
consttualon,only t C W-1 is umdcd, Indluum TMAL-NUMDUR of wens
compunction dou0a.Yon moy arm atmnlf addidenei pagon ifaeeesonry.
drilled:
9.Total welt depth below land smtace: 30s- ( •) 84a,1±osl AliWells: Sub'wit this form witbia 30 days of completion of we11
por muldpte merit I&orb depths jrdi,Qerott fantmple-3 a@2M'and 2@10U'j construction to the following:
10.Static water level below fop of caging: (ft.) Division of Water Resources,Information Processing Unit,
Ijxuter kwl is abore casing,we"+° 1617 Mail Service Qmter,Ralelgh,NC 27699.1617
11.1jorehole dlameter: o og r (in.) 24b.For Infection Wells:' In addition to sending the form to the addre_ssin Zeta
above,also submit one copy of this form within 30 days of completion of well
12.well construction method: constmetion to the followiie.
(te:.auga.roMU.cahie,dtreet push,etea
Division of water Res�ucees,UDdei romtd Wechon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall 3,%Ntce Celiter,Rateigh,NC 27699-106
130.Yield(gpm) biethod of test; a-jk 24c.For Water ft v�&Inlectitm Wells: In addition to sending the form to
bs Ube address(es) above,also submit one copy of ibis form withil130 days of
13b.Disinfection type:6%f bra Amowt: completion of well cnmedon to the county health depaitmem of the comlty
where constructed.