GW1-2021-02426_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD
This form can be used for single or multiple welts f%
I.well Cuatracjtoor,,I�njfoor�mation,
Y.1 S�l Lr V[�� �,4 A '3 2�2 MFR01MTO
ESt DESCRtPTiO\1t'e)(('auiactar\slue N('Wal1 Contractor Cenificarion\timber � ?VG Poe totsitF-eased went OR i iNER to la
i FROM TO DIAMETER Tt!CY-NEss MATERIAL t'
b Y.f ft. fr. 114
(tie 'Get i y i
Compam•'`amc StF.INNER G KG OR TMD . mug ei .ton
(,(� r �}� +\O ' FROM T4 DIAMETER THICK.YESS MATERIAL
2.Well Construction Permit#: � w U Qf ft. ft,
In• I
Icii all apputwhie er11 tinsetruLtitra permit ff.e.(•aunn',Starr.i'ortn+ier.rte.J ft. ft, in.
3.Well Use(check well use): 17 SCREEN
Water Supply tVe)lr FROM TO DUAtETER SLOT 532E THtCR.EW MATERIAL
--Agricultural Cllvlunicipal/Public
CGeothermal(Hesting/Cooling Supply) Vesidential Water Supply(single) fs. h. in•
(CindustrialiCommercial CResidenttal Water Supply(shared) I&GROUT To 'rIATERL.L I €au7L.aCE1MEXT.MEMOD.a�atot:tr
f Clrrsgatiun V ft. 'fr. Mi)r+ Y
Nou-Water ater Supply Well: rr, td.
O'\donitorsng CRecovery
!Injection Well: ft. ft.
GAquifer Recharge --Groundwater Remediation .19..SANDIGRAVELPACK afassolicsiblei
CAquit'er Storaxe and Recovers' C7Sahnity Barrier FROM fr —ft.TO MATERIAL EXPI ACEMENTME'rHOD
.
MAquiftr Test CStormwater Drainage
ft. ft.
GEaperintental Technology DSubsidenee Control 20.DRILLING LOG attach additional sheets if netzssary
=Geothcrmai(ClosedLoop) OTraeer FROM TO DESCRIPTIOT color.)tsrdness.snflreck r,•rainSimtiv.
C:Geothermal(Heating Cooling Return) --C)ther(ex lasn under d2 i Remarks) ft. ft.
� f ft. fr.
0.Date Welt(s)Completed: ft ft
S.Well l.ocatiQn: Q �.�/\ fr. ft.
i f�L��
Faulih.C)%net Fame l`acsliry•!De lifapplieabtej ft. ft,
NF_6". _Mko
ft. ft
Physical Aaress.Cnq,rind Zip 21.REMARI+'3
40nukk3_1 1� 1�m39�73
C'uum4 Parcel(densiticatiou No (PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(If watt field,une lit long is sufficiem)
� Signature ofCenified kveli Contractor Date
6.Is(are)the weli(s):Q'Pcrmanent or ❑Temporary
ity.v/uiuih ttus•jnrut,!krrrh}•crrt+j}•lltut the ire/!(.ij srttc(u'rnj rn+bwrutlrtl to ucr++rtfuntr
.,,(j, ii•Nh iSA MCA('t1;(•.olOa fir ISA 4Y'rrC 02C' 01011 It al t•tu7rfrtK7uut.UtN+tINr(LS told that a
0
7.Is this a repair to an existing welt: --Yes or 4lo cvrpi ref)lets rrtarrllax Agra prr+virtrrl ur the ssrll usiser.
I/thm a of repair•,hll nut knemw well LYatvlruCu(ut MJorynortua drfrfl a•.rphfiu din uaufre q/the
relwtr+fader::2J mmorkv sevitan nr tul the hoc*of this,form. 23.site diagram or additional well details:
You may use the back of this page to provide additional well site details or%veil`
8.Number of wells constructed: � construction derails You may also attach additional pages if necessary
i•i+r mr+1)rple urlrcoca ur iffamraler mVpli•i+elly OM.i'krah the some caaxrlrttcrlart.}yea rare t,NA
,uholw tfnr Jarar J 24.Submittal Instructions.-
9.Total well depth below land surface: 45 {ft.) 24a. For All Wells- Submit this form within 30 days of completion of%%ell
t•iw ondople is el/v/+.st all dteplh..it dh/terrlit texonfply-3@000'lip
3fF lfXt•) construction to the following
pJ 10.Static water lovel below top of easing:„_y,
(ft. Division of Water Quality,Information Processing unit,
11 ilotrrk:rlr.dlxnr<t+.a++}.f.r ) 1617 Mail Service Center,Raleigh,,NC 27699•1617
11.Borehole diameter-. t.t3 3 (in.) 24b. For injection Wells: In addition to sending the form to the address in 24a ..
above, also submit a copy of this form within 30 days of conipictwr, of%veil
12.Wall construction method: n far construction to the following.
(I c auger,rous.;•.cable.ditrcat push.etc.)
Division of Water Quality,Underground Injection Controt Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.field(gptn) ?14eth,d of test: ,,�, 1&m.sL_.._ 24c.For Water Supply 8e Grothertaal Vltells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 01r k o y_* Amount:! completion of well construction to the county health department of the county
:vherc constructed.
Form liW-t North Carotins Dep3nmant of environment sod Natural Resources—Division of Water Quality Revised)au 20 t 3