GW1-2021-00413_Well Construction - GW1_20210129

WELL CONSTRUCTION RECORD 1 This form can be used for single or muhipie welts -` -
I.Will Contractor Inffoor�m�aation::".�,� to
ch}r j s r L1C.f �7 l S 1 i3.WATER=Zti*IES
FROM T DESCRIPTIO\
W411 C'oottactor\ante
91 ?6-A
NC"Well ConttactorCenification Number I 1S OUTER CA$ far maid-eased wells OR LINLIR r1fanfe
FROM TO DIAMETER Tit ti MATERIAL •l'
wt11 �Yf . Inn rt. & 1 lily a( V
Corrtpany Dame 16.INNER 4.19KO I B3K maI cl -toe
FROM TO DLAMET£A Tfttt.'KNESS VtAT£RIAL
Z.Well ConSlractiOn Permit#: ft. ft. in. i
{.rat a{t appkrahk wall masfructir+n permila fix.C'ounry,State,Irartaac'e.smi i
ft. ft. in.
3.Well list(check well use): 17.SCREEN
Water Supply Well: FROM TO I DEAR ETER I 3LOTME :I THICKNESS MATERIAL
3Agricuitural O unicipallPublic ft. ft, in.
']Geothermal(Heating/Cooling Supply) VRResident:ai Water Supply(single) ft. ft.
0IndustrtallCommerciai ❑Residential Water Supply(shared) I&GROUT TO I � I EA1 LNTMETROD&A\: t:Sx
�^.Iu-Whoa ft. �� 'ft. if1'117� Y
\oa-�Cxter Sapph Lftft:
ft. te,
O vionitartng GRecovery
Injection Well: ft. ft.
OAquifer Recharge --Groundwater Remediation Aq.SANDIGRAVEL PACK if livable'
CAquifer Storage and Recovery DSalinity Barrier FROM TO fr. HATERiAL Et=yLACEM ?�r£I'ttQD
ft.
0Aquit'er-1'cst OStormwater Drainage ft. ft
GEaperintental Technology Mubsidence Control 20.DRILLING G attach addidonat sheets if necessary
CGeo&rmat(Closed Loop) OTracer FROM TQ D CRtP'f70Nrrvtor.hardnexa,saWack Not,antinsi='"C.
CQcothermal(Hcatin Coolie Return) COthez(explain under 421 Remarks) rr fe.
ft. fr.
4.Date Wci!(s)Completed.-,
+.NN'eil Location: id nR
Fceili:u.CAuWttNmise Faciliq•iD-(Ifapplicable) fr. ft.
ACC m 12DO W Y Tho psm ft. ft.
Pfgsi Aeldres..Cn),nad Zip 21.R£MAW
o 1!01g56P,5
Coiany Parcel identification No(?IN)
5b.Latitude and Lonottrde in degrees/minutes/seconds or decimal degrees: 22.Certification:
(trwelf field,uie lationg as suffietem)
���• Signature vfCcnified Well Contractor pate
6.is(are)the trrli(s): l�f'rrmaaent or OTemporary
ay.t{L+ftuh dos jnrtl.{hrrrhp errn(y drrtl the wr{{(.NJ na+'_(titeny r•rutelrurtrtl e1 urcorrlunrr
H-uh IJA Aii"AC UIC.O1Aa nr ISA 4C-At'03i 011111 1i'riJ C omtrocitew.6nathinA wid that(I
7.Is this a repair to an existing well: CYes or 1'�.1'a tYlpt elf that moird her heen ptnvided 11;the Well owner:
!1 Asa ra to repmr.fill nut kirtrwt we//Lrurvtruenrirr Altan anon and expleiin the oentare et thy., `" 1
relwir trader=�11 reirwrk.xeL•ttnr+ar au t/ie hack of tlih,fain. " '.�_ '23i.Silt.Bi2gt'ain or additional wCfl details:
•You may use the back of this page ro provide additional well site details tie well`
8.Number of wells constructed: construction details You may also uttach additional pages if necessary
h i+r aoiluple istlrvansr fir ttrnt-w'rater xtrpplt'u elh C.VJ.F:r11h the some rinu7rttc'r�t�{{�itl1ui tin ?�rL1 e, �'
,uhniit(ine/unit ii'i Lt 2si'Su�mittalInstructions-
9.Total well depth below land surface: �✓ (it): 24a`•For'Aft Wells-, Submit this form within 30 days of completion of%tell
7•"nr omiuple w,•1141si all depth..r1 rbljerew fexctttt/tlr- 4'1100`rand 2Gi11Hf)•= "�t r. :"'•.:•s;QAS,tfuCttOtt to the fQ11QWinE.
10.Statit water level below top of easing: {it.) Division of Water Quality,:Information Processing licit,
/twat.-r k:et r.alxicr a u..iu}.rL,e ' 1617 Mail Service C.e nter,Ralelg+h,,N C 27699.1617
11.Borehole diameter: (in.) 24b. For lniteti,Rn Wells: In addition to sending the form to the address in 2441
__above, also submit a copy of this form within 30 days of completion of,veil
12.NVell contraction method. construction to the following. - -
b c auetr.rotay.cable.direst push.etc.)
Division of Water Quality.Underground Injection Control Program,
13.FOR tt'ATER SUPPLY S'VELLS ONLY: 1636 Tait Service Center,Raleigh,NC 27699.1636
13a,field(gam) Method of t..t: a,y- L iml _ 24c.jtia{ Water 5uD tl iv&Geothermal Wallis: In addition to sending the form tit
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: WQ it nr! Amount _ completion of well construction to the county health department of the county
where constructed.
Forni titV-t \oath Carolina Department of Envirorirrnnt and Netural Resouccas—Division of Water Quality Re%,1cd Jan 2013