GW1--03734_Well Construction - GW1_20230602

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LLLI CONSTRUCTION ECQRD MM-11 For Thternal Use Only:
1.Well Contractor information:
r ,TA mEstM 16 t l &c IJL WATtRZDN99
Well ConuaclarNumz - FROM 'IQ DESQFSPT ON
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INC N ttifi ell CoutractarCeotion Number �10 IL
./� / l5:a131iES 2:ASlNG(tbrutald,cased tom}ORLIIVEtt of j
Y J! --D �p� // , I ice'"' most DlebhtEtFlt TffiEMM btATBRrAL
Comtlany Naate
�� ��y IG.IQ ERCA-MGORTtIBING(nMh++rre.Eclosedlao )
�. @�Cf}1l91PUt11QIl�EE'tilll(:- atom I IliAhlhdTtlR I gwrwNmco ktATERIAL
Lilt all applicable well consinicilon permits(i.e.EIIC,Caatxy.Stare.Variance,arc.) D R• �' (a. 2S`'— 1 L ��Z I t/
3.Well Use(cttec6 well use): ft. ft. to.
Water Supply Well: 17.SCBESiY
F80�L TO DIAIttt3TER SLOTSiZIi THIC6'NIPSS p,4AT¢Q7AT
Agricultural �lvtu _ pa1lFublic ft. ftf in.
Geothermal(licatingiCoaling supply) Ewesideaval Water supply(single)
IndustriaUCanitnerciat DResidential Water Supply(shared) OTJT
lEft i13i01t FRMI TO biATFRhtI, E�iPIACt iI<�MAIM8Ddc,L1i[3U1�TP
Non•WaterSupply Well: rt. t>?d ft. t.
F. Monitaring ecovcry ft.
h4eetion Well:
Aquifcr Recharge DGmundwaterRemediation tl:
quftrStorngeandRecovery SalmiEY Barrier IQ9 r+AMINGRAVEPAt�fFCra bIr
31d031 TO 34hTFBL1L IIrtPEACLniE.4ThtE'r80B
quiferTest 05totmwaterDtainage f. ft.
Experimental Technology 0Subsidcnce Control it. it.
(icothermtd(CtascdLoop)8_ D-Trscer ?OFDRlt_dPIGLOGfettadaaddidonrABhce #f
Gcothcltnal(l�caliu /Coolie Return) Other(ex lainunder#`�1Remaft) R " To ➢FSCRIFTIaItttmlm:tzardaeamiUmrlc sizaetcl
(5 ft. r* ft. GVi�( �t'
4.IXte Wells)Completed:S -a3 Well off S(p I". 3 f. r i
djA
Sa.Well Location: it. tt.
M�, C✓�,ssat �e�� ,•t. tt. � :�`� -SLY r��„�.:. ,
CacllitylowuerName FUMY fE:
b Q Lk Rd I M:I( era t aS>?LCe ft: �,
Physical Address,Cdy,aad* it ft.
Illiv.i`•`i:,"il ^ r,. -�1:�i�+J�i�ESl.1
�SL��- �CP�• � �' Z1,h3ElitfAR1SS v 9:�.U�L,-
CcunlY Parcel Identilicatio➢No.(Ptb')
5b.ILatitude cad longitude in degreesingautesiseconds or dedumI degrees:
(ifwelt field,one larllongis suPRclem)
2io trertific➢tiaa:
�`� /�� S- ► - Z
6.Is(➢re)the weII(s) eat or DTeaypararl, Si lutco€CcttifiedWellCouttactor Date
By stgunig ttris form,I hereby Certify that the t+ell(s)tray(were}convrveted in accar#onre
T.Is thus a repair to an eldsttng weU: DYes or a u4th ISANGIC 02C.01a0 or 15A,vCAC 02C.02a0 tYelf Constrrgctian Standards and that a
DIddxisarepair.Jttl out known welt co+ulruc dwe lureofthe copyofdzis record has been prouidedia the{vettoirller_
repair under021 rrmarkrsectionor on.ttte hark ofzhWo m. 73,$Itedl tlgraln ar additional wen detalLs:
8_For GeopraboMP or Closed-Loop Geotlnerntat Webs having the wane Yon may use the hack of this pages is provide nddldowd welt sir.dcra93s or 1vell
comtructiont only 1 OW-1 is ma dud. IndiG=TMAL,NETWDM orwclls cansUuction.dctmb.You may also aneehadditionat pages ifacccsaary.
drilled:
srtRtlrtr'cTag atu�x Cl'[olt�
9 Total well.depth below laadsurface: _ a o (R) 24a.For All Wells Subluit this farm within 30 days of completion of well
Formutliple hells fist all deprhs TMerent(emmptr 3 a200'and2@I,j00'} vonstruetion to the fallowing:
10.Static-%inter level below top of casing:
Ifurtterlerelisaborecwstrtg,the"+A '� 1)ivlsiuno$ZWaterAesflurCes,InFortnation4.batreessvrgL�nit,
(� IL617 Mail Service treater,Raielph,NC 276991617
i1.Borehale diatnett r: �J (ip.) 24h.Iior InIeetion'Wrelts: In addition to sending die form to the address in 24a
M Well contraction method: 0l0 V0, if above:,also submit nee copy of this forte within 30 days of completion of well
V.e.atmer,-lay,cable.accrpuslt,C(Q Construction I01hefo lowlllg:
FOR WATER SUPPLY WELLS ONLY: Division of Water Sesourm,Undergratmtl Injection Control Program'
n( 1636i6Ynil S�iEeeCeIIter,Raleigh,NC.276991636
13a.Yield fRpm) ) Method of test: c�c.1 1 t!1�I-lti o�Q 24t.Bnr Water cunnis&Ialecti n : In addition to sending the farm to
the address(es) above,also submit one.copy Of this form within 3D days of
t36.Disia€ection type: C�10 f i Amounts J,\ Completion Of well construction to the county health department of the county
where contracted.