GW1-2022-00282_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GV- 11
1. Well Contractor Information:
1Vell ConlraclorName
NC Mil CouLmtorCertification Number
Company Name
2. Wei[ Constriletinn t'el'mit l�_ 2 — O l 3
List ull applicable well conlliuction permits (i.e. UIC. Cotui y. State, variance, etc.)
3. Well Use (check well rise):
.Water
DMUnicipal/Pnblic
(lieatinglCoo}ingSupply) DRoWential Water Supply (single)
omnmemint Ddesidential Water Supply (shoed)
Supply Weil:
Recharge DcroundwaterRomediation
Storage and Recovery DSaliaiey Barrier
rest OStora,watcrDminage
carol Technology DSubsidcnce Control
mal (Closed Loop) E37racer
mat (Hcatiti ICoolig Return) nOther (explain underp21 F
4.Date Wells)Completed. ' °1-0J2 WellID6
go. Well Location:
CCU R lk to Ven Kra4
racultylownerName Fulrity IDC (tfapplicable)
79' _trrtxe fs6la -Dr . Mat-,6 , LL
Physical Addrew, Qity, and Zip
MCnmatu- oG Fr9� �79�9b
County Parcel Identifc4MNa.(PlNj
5b.Latitude acid longitude in degreeslminuteslseconds or decimal degrees:
ON& rield, one latllong is sufficiew)
33'"3I'y1.8.W25'5''N 82°H.?�.G9.371el w
6,Is(are) the well(s)ertnaaent or OTempwary
7. Is this a repair to an erristing welt: DYes or
lfthir it a repair. fill ant Imamt.aell canamerion information and expl�n the nature afthe
repairanderO2l remarlessectionoronlhebackofihisform.
>;_Iiar CoaprobehDIDT or Ctlos¢ti_L.00p Ceatitermal Wells baving tha same
commuetion, only 1 QW-1 is accded. Indieam TOTAL I4UMBER ofwens
drilled:
9. Total;yell depth below landsurface: 505 (f{ }
Formahiple.sells tin all depths ifcU ferent (example-3@200'and2@109)
10. Static water level below top of casing: (OB (%)
If tinter lcErlis abare wgng, use "+"
II.BoreholedlOmeter: • 2j— MQ
M Well construd Ion method:.,,,
G.o.auger.mtntY,able,dreatpusb,uc)
FOR WATER SUPPLY 1VELIS ONLY:
13a, Yield {gpim} Alethod of test: �i I11 Cal its ,trek
13b. Disinfection type: i0� Amount; 5 T6rb
I _
For Tnternal Use Only
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Zl REMARHS
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22, C noon:
tutu Of Certified WOU CoOtmcror Date
4 signing thus forth, f hereby eenify that the ueXs) ins fn.-ere) consrrurted in acramanee
uith ISANCAC 02C .0100 or 15ANCAC 02C .0200 {yell Construction Standards and that a
copy ofthis record Itas been provided to the tven auger.
23. Site diagram or additional: well details.
You MRY Me rho bank Of this f► B- To jteovido additional well alto dctaits or wen
construction detat`la. Yon mny lso winch additional pagos i£aeeassury,
&UHIMITALINEUMCM DNS
248. For All Wells: Subrnitlthis form within 30 days of completion of well
construction to the foliowinge
DIvlslon of Water Resources, Information Pmsxssing Unit,
1617 AM Service Center,Ralelgh,NC 276991617
24b. Far inieetion We !in 'addition to sending the form to the address in 24n
above, also submit One copy of this fortis within 30 days of completion of well
coilstrucaoll to the following:
l;
Division of Water Resonrces, Underground Iajecdon Control Program,
1Ct3611�ti1 Sei� CQnter, Raleigh, NC 276991636
24c. For Wafer Supply & Iniertien Wei s: In addition to sending the form to
the addresses) above, also: submit one copy of this form, willtin 30 days of
cmmplt.tion Of well construction to the county health department of the county
where constricted.