HomeMy WebLinkAboutGW1-2021-01162_Well Construction - GW1_20211216 -Print Form
NNTLL Ci?NSTRUCTION RECORD(GQV-11 [i?"IniLgivaelUscOnly-
wen Conk actor Information:
lliii/vl�l`iu l/LJ i �{ I4.'WATERZONES
�A V FROM TO DSSCRiFIiOIv
KC+� Ce=-�ccn C ucxinalCo�>� 'FROM twOki.
Is-OUTERGoi
D R mble
iffir-rrvcce MATffit7AL
G ' 1
co-----y^ �$ l 16.LNMMCASIarGOItTfIsnQG therma2ctosed�l MA;ERFAF.
FROM TO D7e-NaTER. TnrGlQffSS
2.Tvell Construcdon Permit 1: fL fL
Lam.all cRplteable imll carsmleraspereuts(Le.UIC,County,Stat41fM'M rp ems)
I ft. #L in.
3.WeU Use(cheeh:weil use):
Water Supply well: FROM To DIAMts't&Ir sroTsrM Tffi(aavrss aiA7'ERIAI.
Agricultural QMunicipaltPubfic m
G--otne_rmal(HmtinJCoOling Supply) rlResidential Water Supply(single) ft- M �
IndnsniallCot`*ae=e`.al Residential Water Supply(shared)
FROM TO MAT£R7ALI nil METHOD&AvrOtfiT
Irrigation ;t�. fIx
t `1 •
Non-Rrater Supply TVeII: 6J
NLoaitating E_lRecmtery � � _
Injection Well:
Aquifer Recharge E)GmundwaterRemediation 19.SAND/GRAYELPACK ff limble
Saliuui Gamer FRabi TO MATEttrAF. ��Q�TStETEtOD
Aquifer Storage and Recovery ty fr. &
Aquifer Test OStormwater Drainage
Experimental x I Technology nSubsidence Control ft. M
Geatne gal(Closed Loop) Tracer 20.DRILLINGLOG attach ad�l((ional streets if c
FROM TO DESCR1FrtOtC(wSo,lacdam,soHlmek 4 n she.ere)
Coo`ernal{HeatinglCooliagltetumm} Other(e:.plaiaunder#21Remarns) ft. 1 ft
IL
>_Bate Well(s)Completed: well M �
5a.Wall Location: % fL
fL fL
farilirst0�-�Na�e fac@ityID�{3fapp6cable)
Zip 21.RffURK5 _
Ca K Parcel IdenBficationNo-(P"
_o.Latitude and longitude in degreesiminutes/seeands or dedmal degrees: CeTtifieatioD:
—•:.=e'c c i�oya is Sdm-cicnt)
N w O : I 3-
Si of cwfflcd Well Contractor Date
n.L(are)the well(s)MPermanent or OTemporary � this I herehv certify that the uell(s)was(Ivtse)constructed in accordance
�—{ Bvgning farm
?.Is this 2 repair to a oricttnn well Yes or No will 13r1 NCAC 02C.0100 or 15ANC3C 02C.0Z00 I1ell constnctian Stondards and that a
r r is c r ;,`a_r L :r,.uesi r�rsrnu3ar.nrjarmation a�t exglatn the natare ajth
ao pjthfs retard has been provided to the well owner.
r� r� _:;. .__ w.. r c.= e�ckaju'.isjarrrL ?3.Site diagram or additioaatweli details:
r~ _-�_' you may use the back of this page to provide additional well site details or well
8.For Geograba lr3PT a_Clad-Zcog Gzrtthermat Wells having the same construction details.You may also attach additional pages ifnecessary-
construct Go-only I G I-!is rexea- Iicucats TOTAL N MBER of Wells
driIled:_� SUBNITITALINSTRCICTIONB
9.Total well depth below land surface ®Lt `�u ( ) 24a, For All Wells: Submit this form within 30 days of completion of well
For malriple welts Ott a l car rs ii aij =`(�-- 3, 200--qnd?Q100) construction to the following:
l (ft:) Division of Water Resources,information Processing Unit,
10.Static water :e na Bela-inn of racirta: 1617 Mail Service Center,Raleigb,NC 27699 1617
ljxrrter'Awl is ana:•e arr.�:ss��e`-,.
11.Borehole diameter: ym____ Cn•) 24b.For Iniection weA In addition to sending the forma to the address in 24a
above,also submit one copy of this form within 30 days of� completion of well
11 Well construction method: i construction to the following.
[Le.auger;rotary,cable,dot p"=h er.} Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS MN Y: 1636 Mail Service Center,Raleigh,NC 276991636
Method aftxsti 24c For Water Supply&Iniectian Wells: In addition t0 sending the form to
13a.Yield(gpm) I.LJ the address(ts) above, also suhmtt one copy of this form within 30 days of
13b Disinfection type Amount: —
completion of well construction to the county health department of the county
d
where constructed_
• Revised 2 22 3016
_--_ w=h CarolinaDcaaruaent ofEnvitonmental Quuatity-Division of WaterResources