WI0100315_WELL CONSTRUCTION RECORD_20140911

WELL C'ONST�UCTION REC'ni�
Thu corm can be used for single m multiple wells
L Well Cohtractor Information:
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Well Contractor Name
_-01 <2 /--\
NC Well Contractor CertifintionNumber
compaT.
2. Wen Co-mr n tj. Permit #. W l (' � (] (�3 l S
List all applicable xrll�rxvts (Le. County, State Variance, Injection, eAr
3. Well Use (check wen use):
❑Agricultural
�]jGeoWamal (IiezWng;Crxrlirrg Supply)
�Indtuui:tl,tCommerci a1
ClAquifer litcharge
OAquifer Storage. and R_cuvery
I lAquifer Test
DExperi renjal Technoloac
XGeothenlal (Closed I oep)
❑bf luici pat/Pobhc
OResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Ranier
❑Sttamvrater Drainage
11Subsidence Control
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❑Other (explain under #21
4. Date Weil(.) Completed:
as Well Location:
S�� . arn. e6a�
Faculty/t�scder Maine
Cho Facility ID# (if applicable)
e� Rd • it Physical Addiess, City, and :Zip NC
ZS7
Parcel Identification No. (PIN)
For Intcmal Use ONLY:
5h. Latitodr- 4MA Longitude in degmes/minntes/secohds or decimal degrees: L—
i"if seep ficld,�unc lat/long is su�?icienll 22. Ceriafrcau
. ° S D• 85A N _ $ a• i t7 loss
R"
6 Is {are) ncewdlts1. Wplmnallent et• cure of Cutifre We Contractor
�nparary P_cte
7. Is this a repair to an ensuing wen: this is a repaipYes or �iV
If r; fill Out knoxrn a+eQ construction information mud explain the nature of the
repair under 427 remarks see. tiran or on the back ofthis form
& Numberofwelb eorrctrvned• I
Formultiple inection or ncrl-x ater supply nvellx ONLFaith the pane consbrctio
submit one f»m n, you can
9. Total well depth below land surface: 3C)o
For multiple arlla list all depths it o9fferent (exanple- 3C200' and 2@100) (�)
10 Static crater level bdmv top of casing:
If xn5nr leirl is above casing use "+" (R )
11. Borellde diameter. L Cam)
By *Icing this fora; 1 hereby certify that the wrQ(sJ was (were) constructed in accordance
with oft 15A NCRC 02h s been
or Ivi NCo t 02C.0200 if ell Construction Standards and that o
copy of this record has be¢n provided to the *ell oaner.
23. Site diagram or additional well details:
You tray use the back of this page to prolide additional 'veil site details or Well
construction details. You may also attach additional pages if necessarv-
SUBIIIITT_LL INSTUCTIONS
24acon Far A" R'ells'* Submit this fomr Within 30 clays of completion of Well
coivstruction to the following
Thurston of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24k For Tricolor Wells ONLY: In additi
1on to sending the form to the address in
2 Well construction rnetirod: \( b e�Y �\ 24a above also submit a copy of this form within 30 days of c (i. e. auger, rotar}, cabk, direct push, etc.) eonstiuction to the lollouing: tnnpleti4n of well
FOR WATFk SUPPLY RELLS Division of Water Resources, Underground Injection Control ProgrONLY: 1636 Mail Service Center, Raleigh, NC 27699-1&36
am,
13a Yield (Ipm) Method "fled:
f test =a 24c. For Water Stir \ — pph' Be. Infection Wells:
13h Dlshrfecdon Also submit one copy of this fomt within 30 days of completion of
well construction to the county health department of the cowriy where
constnucted-
Fom
North Carolina Department of Environment and Natmal Resources _ NVISImr of Water Resources
Revised August 2013

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