GW1-2022-01582_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD F
This form can be used for single or multiple wells
1.Well Cuntractor Information:
Ohfr1 -�Ohu( �� 14.WrtTfiRZOHES
J C FROM TO I DESCR2PTI0\ �
\Veil Cortmoor Nauxt
t a)15- A
xt'Well Contractor Certification Number 15.OUTER CASP.YG for odd-and Wdls R LINER fit&
FROM TO DlAt+tErER t T@IQLtESS MATERIAL 1'
' Welt �'l1(1 t�G p ft. h. , ai v
(ompam Name 16.1NNER 6ASItC9 OR Dta
W�I f�a33S - FROM TO D1AM TftWILN M MATERIAL i
2.Well Construction Permit M ft. ft. is '
1•nl all apph'wh/r wi(I euuxtrat•tiun pernrlts h.e.CoumtS State,lrartanc..ric./ ft. h. in•'
3.Well Use(check well use): 27.SCREEN
Water Supply Well: FROM TO DUhtETER 5EAT512E THiCK�tESS MATERIAL
ft.
=Agricultural 0 iunicipal/Public
0^ueothennal(Heating/Cooling Supply) esidenual Water Supply(single) ft. fc. n•
slndustrialiCommercizi 0Residential Water Supply(shared) I&GROUT
pp y FROM ITO A MATERLLL EhiPLACEME%TMETROD sr AMOt'\7
i CIrrigatior, fr. �U"fa �ry1x Y
Nou-Water Supply Well:
fe. fe,
Q'v10n(taring ❑Recovery
Injection Well: fL ft.
MAquifer Recharge :Groundwater Remediation 19.SANDlGRAV PACt; if ieabte
FROM TO MATERIAL E?SFt.► E.Yr>t£TttOD
OAqutfrr Storage and Recovery OSalutity Barrierfr. n,
E Aquifer"!'rst CStormwaterDrainaze
CEuperkiiental Ti.•ehnoiogy OSubsidence Control 20.DRILLING LOG attach addrd0nil sheen if Aeassary
CCcothermal(Closed Loop) OTraeer RO. TO DESCRIF7 \ eoter,hardaestseiYreek c.-rainr+se,erc.l
70
CGeothermal(Scatina Cooline Return) COther(explain under 021 Remarks) ft. ft.
4.Date Welt(s)Completed: m�Q _....o' 6
;.Well
Location: fr. ft. ^ i
V[z l_i it. ft.
rta�cAia.ih�ne.,Na;ne 1'actlin•10-pfapplieablej ft. ft.
pp 1 11 •''i
Pit sicai Address.Cm,nad Zip 21.REMARIrS
9013753
Cnuru. Parcel IdetuifieationNo (PIN)
Sb.Latitude and Longitude is degrees/minutes/secouds or dcelmai degrees: 22•Certification:
pt wolt:laid.one tatlong is suflieten:)
kv
Signattue ofCcrtified Nell Contractor Data
6.is(are)the well(s): Q�ermanent or OTem ore
, P rY Ky si5nutg lhts•jt,nn.I hrrrhy'earn(}'that fhr u•rl/(.a/tit at'(st'rray rn,ttlrae+rrl n,eterrmk„Kr
with 1$A Ni-At•aIV.010u nr 15.4 SCAT'ON WOO 1Yei1 lino rt
7.Is this a repair to att existing well: Oyes or 94lo caps ell this rrt»rd hox hertz provided tq the it•r•I/mi-ner.
t/then ra tr rrpatn fill nut Al~we]/crutwracwrup toJarntaoirrt and a xidean the nature of the ,
o
repair under 2/rc++rork..cKtmn or at;file hack oJthir farm. y Site diagram or additional well details:
f you u may use the back of this page to provide addiuona!%%'ell sin details or%%•ell'
8.Number of wells constructed: construction details You may also attach additional pages if neeessaryv
Gar a,nitrplr r,rlra•m+,r ar nrui•u•nfrrxapp/t•a ells ONI.Y uvlh the some C7Wtramon.Yfu,colt a:1
,uhnr,t ru,e I„rue 2 24.5nbmittat instructions:
9.Total well depth belmv land surface: 305� {ft.) 24a• For All Wells: Submit this form within 30 days of compictwn :tf%tell
Faraditple ue/k/ulal/deplh.d ifiuerewfeamp/t••3!g200,O1U12 cid NJfft construction to the following
C)n
10.Static water level below top of casing: n-t A) Division of Water ce Center
r a Raleigh,
INCProcessing Unit,
:1 came level i,oh+rr iG17�Iai!Service Center,Raleigh, 27(r99-i617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
lE�
above, also submit a copy of this form within 30 days of completion of well12.Well construction method: �n 'Q�' Construction to the following.
(t a auger,rntY'1'.Csbte.dune push,etc.)
Division of Rater Quality.Ltndereround injection(:Dario!Program,
(3.FOR WATER SL�PI_Y WELLS O'�LY: 1636 Mail Service Center,Raleigh,NC 276"-1636
i 8 �1� I 24c.Far Water SuDnly&Geotltertnal V1`eits: In addition to sending t:c form to
13a.1'icid M - Method of test: �_
(gPm) ` tote addresses)above, also submit one Icopy of this farm wnhm 30 days of
lab Disinfection type: Chlorin_ Amount _ completion of%veil construction to the county health department of the county
where constructed.
form Ci W-t North Caratina Department of Environment grid Natural Resoua:es-Division of Wsser Quality Xc%,scd Jar. 2013