GW1-2021-05785_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) Ear luimDal use Only.
CaubvCtor
Daniel C.Veltri f,E: -
FROM 7O DESCHIMON
wencuauwwrNam
Go NCWC 4368 n n �
n n j
MWeRCanuactarCkrfificaticaNmcber la AUiER.CAS IG: `..IDa�li n its`OH_T 111BR :*
Maupin well drilfng FROM TO DtAMEM I 111 >rss '" .tIF `
t ft. m n 2 sdt-40 ttvc
CoagpanyName
ib CM MGORTU rxG(
L WED Construction Permitt#: FROM I TO I DUttt M I 7atCXVM I MAIMMAL
listaUappLaahhnsea prsaits(ca WC Ca M..Maft vwi eee,ac) n n. to.
3.we8 use tateekwet Dse): n n hL I
water Supply Welt tS iGRETO I otA scarsr }i uwnL
D1vlanicipam". as n sa ft. 2 1 a.or0 1 tw►40 JPVC
im Geothermal(HeafmgToobrig Supply) DResideutiai Water Supply(smee) n n
rndustrhWCornmercid [31tesk aetiat Water Stgr*(shmd) !&GROUT
FROM TO MATERIAL EMPIACOMEMB EMOD R AatODNr
Non-waterSw*Weft: t U- or ft. tolefts v
VAqwfffb-rTaa
Rocavery n n
tt ruge OOmuadr�erRemodistionge and Recovery E}Satiniry Barrier FROMI TO MATERX"13Stormwater Drainage es• n ya n 1ATechoolow DSubsidenceContral n ,nClnsedtArop) Dtwoxrit Retum Other tam tender#2 t Remarks) t ROM TO DESCRIFUDN� adthaeY slue
t n 4 ft Drown[grey day
4.Date Wdks)CO=Fkft&28 Sept 21 wen JD# 4 ft is ttrown sand
So.Wes Loeafron: r: n ss n grey sa w
Ken Carbta ss n 49 n "day
Fecfiity/OweerNam FaerL'tyM#(ifopplirabie) 43 R' as R' gwday
115 Nautit al Lane,Bells Island 88 fL 98 n gory sand
n (�
i'4ysicai Addxcss City,and Zip 27 RFMARrGS
currituck t t w
County parcel MeaffestionNo{PIN} t t• 'J'4'_` i 'l
5b.Latitude and tonetnde in degreesWuntesisecords or decimal degrees:
(ifweu field,One bu is sufficient) 2L Certification:
36:93169 N a5.99839 �y----- 29 sept 21
6.1s(am)the weWs)OPermanseat or (['rmporary s eu []rate
By sigmT this forth,2 hereby or*d w the wetl(s)ww(were)wastraded in a—dmtae
7.Is tMs a repAr Ua m ezisft weM QYes or JONo lash 15A ArCAC 02C.0100 ar 15A NCAC 02C.0200 We Canxavcatott Standards and drat a
!f this sa rzrrzfr,feel oat(umtra twefl aranscriart it formaiimaml et plain the man"Ofthe c*yofilm recard has been provi&d to the nd1 otow
rtpairmrder 021#emff ssecdm orou dx bou*ofncfcfo m. 23.Site diagram or sul ifimW weR ddatls: ;
&Far GeepmWDPT or Clased4Lzop Ceathermal wells having the same Yon map use the track of this page to provide addftiOnst Wes site detail ar Veit
constnatiaa,only 1 GW-1 is need tndieate'fMAL NUMBER ofwcHs construction detains.You may also abaci adMoned paps if necessary.
WBNATrA JMSlltlfcrlaxs
9 Totat well dep&below laudsurike:98 L) 24a.For AB Wdls Submit this fomt within 30 days of coagdMon of weg
For a *t&r tall dgWn gdlemw( 3WOO'°nd 2@1W) Construction to the fouawing:
1&Static waft level below UopofCasiW.8 00 DjvisianofwaterRes mvminformatimProcenhgi)nit,
41awe►lewd isahoneaosstg,use"+^ 1617 Mal Service Cm w,PAWgANC 2.76994617
1 L Eorehote aja r 4 7/8 (in.) 24h.For injection wens: in addition to sending the form to the addmn in 24a
Mild above,also submit one cam+of this form within 30 days of eomptetion of weU
M wen aaMtruCOu t rotary construction to the followings
(ta sage.eatery,cable,do-paste,cic.)
DiYjSiaD of water Ftesaurees,Uudergramd 111jec3iaet COnfrai l'rngram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mas Service Centrx,BaNWNC 27fiW1636
13a.Yield(gpm)25 Methad of test:la'pum 24c.For water Smm[v&19MP—D Weiss 6t addition to satding the form to
the address(es)strove,also submit one copy of this fait within 30 days of
13h,Dhinfedlon type:kg-hate Amount:4 OZ completion of weft construction to the county heahh dgwitment of the sty
where constructed.
FOwtGW--I Naith CAmlina DepwonentofFrmrar ncutalQuality-DivmwnO£WaterResoatas Revised222-201b
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