GW1-2021-06611_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD F .0, IM:
This form can be used for single or multiple wells
I.welt contractor Information-
.14.WATERZONES
(1hrisioohiY11111 GreeflQ FROM I TO I DESCRIPTION
7
tractor N8111i - I ft.
7
?jS- Ato{ar C.O."ton I Ft.
\'('Well Contractor Ceniflcation.NNurnber I IS.OUTER CASING Uftbir vveft)OR LINER rif an
FROM TO DIAMETER I MATERIAL
WILI r>yl I I I rZA () ft, rl FT ft. CD1 P Ve-
'16 "ASIN' x eloaed
CZfij I 11C NO OR
2.Well Construction Permit 4_rmiq FROM ft. To � ft.- DIAMETER THICIC.'Ess MATERIAL
Stater.
3.Well Use(chick%veil use):
17.SCREEN
Water Supply Kell: FROM To OIAhtETER aLOTSIZE T1itCKVESS MATERIAL
OAgricultural cmunicipalipublic ft, ft.
00cothermal(Heating/Cooling Supply) Q4esidenllal Water Supply(single)
rilndustrtaliCommercizi Olkesidential Water Supply(shared) I&GROUT
FROM To MATERIAL I E.%IPL4,C"FT-,METHOD&A.%IOC'.',"T
Nou-NVater Supply Well:
O.Monitoring CRecovm
I Ffnit—cfioft Well: ft. ft.
0Aquiler Rechargc M-Groundwater Remediation 19.SAND/GRAVEL PACK lif avolicablel:
CAqw fer Storage and Rtcovery MSahniry Barrier FROM fr, I I TO I MATERIAL I EXPIAC&MEWMETHOD
ClAquirer TCsE CSiormwater Drainage
C E.xperim.ental Technology 0- Subsidence Control ft. ft.
20.DRILLING LOG(attach additional shce
=Cteothermal(Ciosed Loop) OTracer —FJLOX1 TO DESCRIPIVJONW�k mot.train simetc.)
CGoollicrinal(Healing/Cooline Return) 00ther(cylain under 421 Remarks) ft. ft. I
ft. ft.
4.Date Well(s)Completed: (Jq Orb@ 11
fa fe.
5-Well Location: ft. ft.
MS&XqM(17 AAV ft. ft.
Fjcdh%.0%k:%cr Janie i Facllit%ID-.('1filiplicable) ft. ft.
2549 Lann Mnunkifr) Pa We 1o4c? - ft. ft.
Ph)sical Address.CW,--ind Zip 21.REMARKS
Ca Oba AQqgj()q&
Colnll.k Parcel Idetuificatim ko(Pl3N)
5b,Latitude and Longitude in degreestminutes/sevouds;or decimal degrees: 22.Certification:
(divcll field,one lationg;ssuflictent)
Signature ofCcrtiflod Well Contractor Datc
6. Is(are)the well(s): a(permanent or OTe.mpors ry Bysipting ihisfarin,/herrhj-cert!b-that the wel/Ai sias(were;riapirijoed tit motritanev
with IJA IWACOC.010(i nr ISAAVAC ON* (11111i illed t*,ils,trtvltt�ti.��ftoilbir(l�%tindflyrit(I
7.Is this a repair to an existing well: OVes or 940 rapt q1dim the wethoswer.
If 1;10-,I.,c'retitn',fill nut k1i'mil well Lyawfuritrup sqlarinotion anclerploin thernenow(If the
rerwn-tinder�:21 nrowirkv verttrit,or an the hack q1diix join. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or woll
8.Number of wells constructed: i construction details You may also attach additional pages if necessary
hir fni'lliple talrown uellv Ovl.;*will-,the.came raat7tucriat.ytnr rail
'Uhalit cin"/'Jent 24.Submittal Instructions-
9.T L3 otal will depth below land surface: (ft.) 24a. For AH Wells-, Submit this form within 30 dais of compIction of wail
- 0-ii I -
Frir nadirlle t ells iki all depdt<ii'dillen-jil textusittiv-3f 21 1*oad 2 cy lou').k W consiruction to the followine
10.Static water level below top of easing: 7 tJ
X (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigtit,NC 27699.1617
I 1.Borehole diameter: (in.) 24b. For Iniection)ftlis: In addition to sending the farm to the address in 24a
above, also submit a copy of this form within 30 days ofconipicuon. of wril
12.Well construction method. afa � C w.
r onstruction to the follo ng.
lz
b 4 Auger,roixy.;;able.direst push,em.) Division of Water Quality.Underground Injection Control Program,
[13.FOR WATER SUPPLY WELLS 01NLV: 1636 Mail Service Center,Raleigh,NC 27699.1636
I 3a.field(gpm) M Method oftest: aly, Rlliokl 24c,Far Water SugnIv At Geothermal Wells: In addition to sending the form it,
he 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
13b.Disinfection Amount: where constructed.
U
Form Ow.I North Carolina Depirnnont o(govironment and Natunil Resomm—oitsion of Water Quality ke-sddjan 2013