413451_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Well ContractorNa
mania Certification um
NC W
Company Name pJ
2. Well Construction Permit # t (y 010151
List all applicable well construction pernuls Be, Couny, Stale, Parlance, etc)
3. Well Use (check well use):
W jjter Supply Well:
*gricuitural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
❑Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4.-Date Wells) Completed: / 4 -09 Well ID#
Wellpcajlon:
For Internal Use ONLY:
41315
FROM
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DIAMETER
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is ::tx7 S.1_`7A`fF__.+tY zriL 3a v a�ilr ;10.`.) Ei:7'n'u"
FROM
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ft.
MATERIAL
MATERIAL
MATERIAL
EMPLACEMENTMETHOD > AMOU
EMPLACEMENT METHOD
IPairrI:d3 leer,
IPI'IONth,.nuas.rtM...la.lscsnWata
APR231013
Aquifer Protection SeCBir t .;
ty
iD#(if appliii sable)
3SC11LeOc/ �
J
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
3 i.752926 N 77 430if11 W
6. Is (are) the well(s): °Permanent or ®Temporary
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair, Jill oul known well construction information and explain! pgiv
repair under #11 remarks section or on t e b ck ofih
8. Number of wells constructed: " •e
For niuMple Infection or non -water supply wells ONLY with the same eons:w et:on, you ct/n
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths ifd ferent (example- 3®200' and 2Q100)
10. Static water level below fop of casing:
Ifwater level is above casing use "+"
11. Dorehole diameter: '31� (in.)
12. Well construction method: 1Y
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
132. Yield (gpm) fp�M�p{e�Ithodp�to�tffptttepstt::
13b. Disinfection type.
®'°RjtR6Jsttts
22. Certtticatlon:
Signature ofCo tiled Well Con tor
By signing Ihts form, 1 hereby ce t(fy that the wells) was ttverej cs Werted in accordance
with 13A NCACOY:,u10li or i>ANC'AC (J C.0100 Weil Consvuchun Stamiarav and o.at a
copy alibis record has been provided w the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this fonn within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
•
24b.-For Iniection Wells: In addition -to sending the fonn to the address in-24a
above, also submit a copy of this form within 30 days of completion of well.
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunuly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one. copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW1
MAY 0 6 261
orm Carolina Department 0/Environment and Natural Resources — Division of Water Quality
Aquifer Protectirin Scirtinn
Revised Jan. 2013