GW1-2022-00919_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD F
This form can be used for sinete or multiple wells
1.Well Contractor Information-
13.WATfiRZQ*lg5
F�tOMI TO DESCRIPTtO\ �
1\'e11 C'ontracror Nainc
9 35. Ft
Well Contractor Certification Number S.OUTER CASING far misid•mxd iveils R LINER Us
FR0.H TO OGatl'TER t Ygra ss MATERIAL ,i'
1n�11 by', l ft. . fr. J atI PVC
Compare "zinc 16.1NN£R CAS[NG OR '
^ I ..03�•'//] FROM DIAM R ml TtttCK.�ESS MATERIAL I
RI 2.Well Construction Permit it: _I y/ ft. ".
1.,.,1 all opph'whir erll tnasiructian permits h.e.Uounn',State,1'arrancc.elej
ft. R. in. j
3.Well list(check well use): 17.SCREEN
Water Supply Well: FROM TO OLUUETER 5LOT512E TAtCK�FESS MATERIAL
ft. fr. in.
OAgricultural 0MUnicipal1Public
OCeothermal(teatin Coolinag-Supply) �t`sident:al Water SuPPtY(single) Er. ft. rn•
j MindustriaiiCommerciai ❑Residential Water Supply(shared) 1&GROifi
FROM TO MATERLII El1Pi.AC£ME1T. ETftOD 6 AMOC'\T
f�Irrigaticin fr. a�`ft. 1`frTl7� Y
Nou-Wifiter Supply Well: ft to
101vionitoring ❑Recover h,
i Injection Well:
0Aquifer Recharge OGroundwster Remedial= 19..SAIND/GRAVE}.PACT: if e
FROM TO MATERIAL E?tPLACEmLW.%tETt100
OAquitar Storaet and Recovery OSatinity Barrier fr. ft.
[DAquiler Test uStonnwater Drainage
ft. ft.
GEaperktiental Technology OSubsidence Control 20.DRILLI."JG LOG attach additional sheets if necsssary
IOGeothermat(Closed Loop) OTracer VZOM To DESCRIP170Y color,pardaessseiY e.•minsize.etc.t
i CGcotltcr Y mal( catina Coolme Return) GOther(cx liun under 021 Remarks) re fr.
fr. ft.
4.Date Welt(s)Completed: Qe+ 13 2Q@ 1 ft, ft.
i Well Location: fr. ft.
rt.
i:acAiq.Chuic:Max i:acilin)D=pfapplicable) ft. is. 7202?
I�� W Ph 1bedL �- ft. ft
F'��lss.Cn%,and Zip 21.REMARK ;1
ll „T
... ............. ... . ...i' ail
C ount% Parcel ideruifeatial No(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
prwcU Seid,one litloag is suffieten)
Sigrtatute of Certified Well Contractor Date
6.is(are)the well(s): lz ermanent or OTemporary ay,ejv.apex ihra join,/hetrhj•cer4y that Me urNfy ttai'61eny rruny'IruUrd ru rna,raJunct
with 15A NC'AC'rta'.0iOU nr 15A 4VAC 03e' V.,Ml lf'eiJ t'unafrr,ctn,u,6r.,rrinrlt and lhrn u
i.Is this a repair to an existing well: Oyes or V<0 apt q1 tha record hat burn provided rn 1he wet/onwer.
1j plea m a reparr.6p out kronen well trawipwiniii informonvo and virplutn the uan,re 41h�•
repair under:21 retimrkr.rrcitan nr mt die hack of thtt form. you
Site use theiagram Or k o additions)l well oprodetails:
' You may use the back of this page to provide addiuonal well sin details ur\\•ell'
8.Number of wells constructed: construction dctails You may also attach additional pages if necessary
J•i,r mwnpl,•rntrauny or,wn•wan•rmippn•uenv O,N1.Y n91h the some cnRtpraetion.ynil ran
,irhnutr,nr juror 24.Submittal Instructions-
Submit
Total well depth below land surface: � � (ft.) 14a. For A�etls: Submit this fixin within 3U dap, of completwn oC sell
vor u+tilblile i,;llrhoall deprh.,ifdiftereat(exuatplr•JIR2 w',ond.i!lfiff) cOnslruclion to the following
10.Static water level below top of casing: +vl (ft.) Division of Water Qaaliry,information Processing trait,
1617 Mail Service Center,Raleigh,'NC 27699.1617
/R I 24b. For lnjection Wells: In addition to'sending the i'orm to the address in 24s
11.Borehole diameter: W (in.y
above, also submit a copy or this form within 30 da\•s or comolrtwr. of ivcu
12.Well construction method: g}n�t�Y� construction to the following.
be auger,rotary.cubit.dia"t push,ere.)
Division of R'attr Qoaliry,Underground Injection Control Pfogram,
13.FOR WATER SLtPPI-!'WELLS 0>qLN': 1636 Mail Service Center,Raleigh,NC 276".1636
j 134.1'ieW h4ethod of test:
I j 14c.for Water Snon�v&Gratleermal In addition to striding the form to
(e'Pm1 the a oress(cs)Suppl also eotbesubmit our coPY of this form within 30 days of
13b.Disinfection type: Ie1,OI'tY1P_ Amount _ completion of well construction to the county health departmem of the county
where constructed.
Form C'i\\•'-t -anh Carolina Department of Environment and Natural Resoutees-Division of water Quality Re\,Sad Jar, 2013