GW1-2021-00529_Well Construction - GW1_20210315

WELL.CONSTRUCTION RECORD F
This form can be used for single or multiple wells
1."'ell Contractor Information:
L �;Y.j 5 f iliJ f tY� e �� '`�a`," q�•1\i 14.IM - ZQh1 ER ES
r S�
1 F7tOM TO DESCRlPT10\
hell Cbuttacror vauu ,l .,-,-U i �
�y� 't S.01TIER CASING for maid-cexd we8a OR LIZIER a
NC'WellCotttraeurCenification\timber :r• �:+ FROM To DLIMETER iEss I MATERIAL I'
ft. ( + of V
Compa++y Kame r `t j';'t 16.INNER CASING OR
Q FROM TO DtAMErLAS THtM%= MATERIAL
L Well Construction Permit M O v �• ft. ft. "r }
appkewhle well trrurtruclion peneits/r.e.t bwnAy Srore,Marian ee.etc.) ft. in.
I
3.Well list(check well cue): 17.5CR£EN
�lrattr Supply Well: PRO?it TO DLthttTE S1ATStZE THTCK�FESS MATERIAL
ft. fs
=Agricultural cmunicipal/public
00cothennal(Heating/Cooling Supply) VResidential Water Supply(single) Et.
OlndustnaliCtunmerciai i7Resennal Water Supply{shared) 1&GROLT
{ id FROM TO MATERLti EatM ACEVITME[fIOD&AMOt'\T
�Irrsaatwn ft. ao 'fa M+.A,
Nou-Water Supply Well: Et. ft.
Mdonitoring ❑Recovers
Injection Well: l
uAquifer Recharge CGroundwater Remediattoa FROSAIrD/GRAVEL PACK M I MATE�Ie E%1FlAC£MLN•rl1FrHoD
MAquifer Storage and Recovery OSahnity Barrier tt: ft.
I
;_,Aquifer Trm OStorinwater Drainage ft. I ft.
CEaperiniental Tcchnology =Subsidence Control 20 DRILLLHG LOG attach additional sheets if ttasaaary
Geothermal(Closed Loop) =Tracer ranat TO DESCRIMO\ rohr.lurdmt•sei}Jreek rriiirise etc.i
CGeothcrrnal(ScatinglCooling Return) Ggther(explain under x21 Remarks) ft- ft.
fe. fr.
4.Date Welt(s)Completed: 20 I ft, ft.
5.Weil I, don, '�
tit M f(II ` ' p
1rxAit).biu vans --j i., facility ID-tifapplicab)e) ft. ft.
Enoineer l�s�-�c ft. ft.
Pigsical 1411.5s.('n),mad Z' 21.REMAM
Court, Parcel lderu+i;oationNo(PIN)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 32.Certification:
field,one latlong is suflieten.)
/ Signature ofConified Well Contractor Date
6.Is(are)the well(s): di ermanent or OTemporary Hy.11pung lhn faun,l drrthy certify thud the irelJ(,i�RYA'AVOA*j ClUXOM&IV/tw ertenrtlnner
a•uir lSti Kt"Af'tl?r'.0/Ou ar 15A.4t'Af'tl?i' UIl)el lYeiJ!'no.rrratxur Uanrlanit unJ lhut u
7.Is this a repair to an existing well: Oyes or 14NNo swpt qJ rhos recr,rd has hrr(i provided in the arN n+rner.
//rhos rs a repmr,•fill out krwuw well trwt+lrac000 wwerrwontw and exrdeda the nourre u/the 23.Site diagram or additional well details:
relwir under /rtwwrkr zes t(nn or an the hank of this fnnn.
I you may use the back of this page to provide addiuonal well site:details ur tttill'
8.Number of wells constructed: construction details you may also attach additional pages if neceseurY
/•ter nurltrple ewlectina fir nwi•n'Mty supph a rile ONL Y with lhr same ewartrrtetfnH.}ru emir
,uhnnl ewe 1„rror � 24.5ubmittal Instructions:
9.Total well depth below land solace: 505 {ft.) 24a. For All Wells: Submit this fort within 30 days of completion of well
Forined .•Nldetwllhrla//depth..ifde/terealrexwwph•-¢92M)'MullhMitt construction to the following
itog:, 140 (ft.) Division of Water Quality,information Processing(init,
tit.Static waterltvti_belaw topof eas
--- -- -- 1617 VIaH Service Center,Raleigh,NC-27699•1617
/loot..-r lrrrl t.uhrn•r un,ru�.toe.' .. - - ----_-.___._ .._-
t 24b. For Injection Webs: In addition to sending the i'orm to the address in 24a
11.Borehole diameter (iu.)
above, also submit a copy vs'this form within30 days of cumpkliot: of twill
12.Well construction mtthod: n far� construction to the following•
I c auger,rulwy.cable,direst push,em.) Division of Water Qual(ty,.Underground injection Control Proarnm,
I3.FOR WATER SUPPLY WELLS ONLY: 1636 Mait Service Center,Raleigh,NC 27699.1636
t ! 24c,j of Water S"^^t" (;eothermal Wells: In addition to sending the form to
13a.yield(gpm) t Method of test: lice addreWees) above, also submit one copy of this form wuhin 30 days of
{r1 t f31'iY1� Amount completion of well construction to the county health department of the count,
33b,Disinfection type: — _ where constructed.
' Reused Jan 20 l3
Fern)OW t North Carolina Department of Environment and Nammi Resources-Division of Waw Quality