GW1-2022-09389_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD {
This form can be used for sicee or multiple wells For Internal Use ONLY:
1-Well COatr2etor Informati,,:
/9lRf/�i-e � � �1 tA.WATER,ZONES
Well Contractor Name FROM TO DES EMOIN i
fi Ch ft `
_22 —A�q p ft / Z rc
NC Well ContractorCertirrearionNumber :15Of1TER.EE1$ING formal fi!eils RLII!IER'rfa liestile ..
B�IQ'netgs Well ®rell®6@ Inc. 'EOM To Dc�ntertrtt i TMCK01 MAtE�u
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Nae / AMC QR-TUBING 't�eftinalclos�dl
2.Well COmStRICtiOn Permit#: d 7—�r EOM TO DUMB � T
List all applicable"tt construction 0. ry e ft ft is permits e.Cmai Slot Varlaeca,etc)
3.Well Use(check well use): & hL
Water Supply We11: 7 .SCIt$EN:'
11JAgricultural PROM TO DIAMECER SI,OTSlZ6 TRICKINESS MATERIAL
O—!Municipal/Public• it ft ;o•
❑Geothermal(tieating(Coolimg Supply) [tlKtsidential Water Supply(single) is ft in
❑industrial/Commercial OResidential Water Supply(shared)
❑T i ation PROM TO
ft ft RggatATERUL Et O'CFJVIEINT METHOD'&AMOUNTment
Non-Water Supply Well: Land/
❑Monitoring ❑Recovery ft rc
Injection WeIL S ft
❑Aquifer Recharge ❑GmundwaterReniediation "Y9'SAlYb/GI2141I�;1?eiCIC if" titiitile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M.�TFRIAL DttvucFhrEaii rttergon
❑AquiferTesE rc &
OStotmwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer ZO: LiIYG`i;OG`atfaib:3dr7idttu falreets.ifriee sa
17Gcothe[mal(Heating/Cooli Reruns FROM ro DESCRIPTION'wlor buds soiUrock
ClOthtx(explain under#21 R.emarks ft 2 it sae:et`"
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ns�i, �
4_Date Wells Completed: '/�2 �CILS� 2 & ft
O P .�We11ID# n
Sa.Well Location: 0
ft ft.
FRciuty/Qwncrtra.ic f
Facifityi[TI(ifappliablb) .,,
l�lr�lc�� ft ft —
Plrysieal Address,City,and Zip & ft
::xr:. tlsnRles: 7,77
County rp R G ��J pal idenrificabovNo.(Pn
5b.Latitude•and Longifade in degrees/minptes/seeondsor dedmal degrees:
ONveU field,one Wong is sufficient) 22.Certification:
6'Is are'the Wells: e $rgmeofCetnfieQ wen,Co Date
or OTemporaly
ey slIntng.t 4 form,I hereby certify char the•wells)was(were)corr.,•trucred in a.,clan.
7.Isthis•a.repair toanexisting..wefi: ❑Yes or .BiPo wiflrlS.IilCriCO2C.0100orISA-NCACO2C.0200'WellCinstructlonStan&rdsmidthato
If this is a repots,fill our known wolf construction irrformaLion ond.,aggjin dm nature 0Jlhr �pyV"*s!"niharbeen pmvlded to:the u'dl owner_
repair under921 remarkr secrion or on.1h,backof of form. 23.Site'diiagrim or aiddittond1wen details:
Number of wells constructed:
You rosy use Bic back of this page to provide additional well.site&Wls or well
For
_ cdnstntction details. You tray also.attaeh additional
For nefe injectionfam. ar noa-rvarersupply weUs ONZYwuh the sarrre wo ucGon,you can pages•if nr cessary
submit one SUIi1VIIZMAI,IN$TUCTIONS
9.Total'well depth below land surfaice: 5 ZZ) (ft) z4a Far All wells Submit this form within 30
Forrmdripfe weUs list all depths ifdtJjeretit�esampfe-3Q200'artdl 00 days of Completion of well
constinctidn tothe 011owing:
10.Static water26 level below top of casing: (ft) Division of Water Quality.Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service.Center,Raleigh,NC 276994617
11.Borehole diameter. i
_165—fin) 24b.For 11 etiom.We11s: In addition to�stiifling the form to the address in 24a
shove,also Subtrrit a copy of this form within 30 days of completion of well
12.Wellconstructionmethod: lLt r
r /v] crntshuctinntothefollowing.(t.e.auger.rotary,-ble,direct push,etc•)[/t
FOR WATER SUPPLY WELLS ONLY: Division of Water Qaality,Underground Injectioa Control Program,
,
? 1636 P"l Service Center Raleigh,NC 27699=16M
I3a.Yield(gpm) J Method oftest 131OWI120 minutes 24m I?'orW,2 er.Su00ly&Iniectioh Well s In addition to sending the form to
HTH 3® tite addresses)rdrove,also submit one copy of this form within 30 days of
136.Dlsinfcetian type: Amomat: completion of well wns"ction to the 11 ty health department of the county
where constructed.
1
Frmn GW Nortlr l orotirm D epartn—Of Fnvkonm=t�NaturalResources-DivisionofWater(=1hy il.
Revised Jan.2013
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