GW1-2022-03212_Well Construction - GW1_20220309

WELL CONSTRUCTION RECORDF
This form can be used for sink or multiple welts
1.Well Cuatractor information:
ni 4_f i C h-•I /"( _eeu)Q 13.WATBRZQNFS
n J TL�ir (sr C PROM TAD DESCSttPTtO� '
fl, ft. j
Well CCoonimctor Nano a
IS.Ot1TER CkSiItFG for ivsBs '�IBR
Nc'Weil{Contractor Ce"ification.NuMer FROM To DtAllt TIR&'i@Jt� !lATFJtIAL i'
Z 1n�1[ �Yi [If1C/i ft. ft• ! at Y
Company Kai a 1tL INtNER t>_AD Olt
FROM DLWKTLR Tf FcLN= MATERIAL
2.well Construction Permit
i
it.t all afph'tvhk well viaxiracliun permits 6.9.(banA%State,Palmier.elc./ ft.
3.Well list(check well use): i%SCREEN
Water Supply VVeI): FRtSM To DrAmmit S[AT51ZE TA[CK�ILSS 1tATERtAL
It. in.
ZA;ricultural O 4unicipal/Public
E20cothermal(Heatinp/Cooling Supply) Residemial Water Supp1Y(single) ,
ft. ft. in.
IL a
MIndustriaiiCommerciai OPesidenttal Water Supply(shared) FROM UT
M TO MATF3i RLA T. ETRtIDe+AMOI'\T
Clrrivattur,
Non-Wa tr Supply Well: fe, it.
Q'vlonitaring CRetoven ft, ft.
i Injection Wen:
GAquifer Recharge -Groundwater Rcntediation 19.."NDMR I KO '
FROM To MATERLtL CatYlAC£M>,rr]lEIHOD
CAyuiter Storage and Recovery Malwity Barrier
i�Aovifrr'1'rst 'uSlormwatir Drainage ft. ft.
i
CExperi iiental Technology nSubsidence Control 211.DR[LLL*tG LOG attacbaeddidatnl ifaicessary
-Geothermal(Ciosed Loop) OTrater TO RtPFtON eoter.t+ndaesr seiurxk •r+ii+aiu etc l
COecthermal(HeatingCoollite Retum) GOther lain under 021 Remarks
ft. ft.
well(s)4.Date well(s)Completed: 61 09� �> ft. ft.
5.Well Location:
i
Rf a , r Pf7(3L' rat.
rxrii:).Ch,ae:Na+ire �acslitylD-pfapplieable) ft.
fg is fiogr f+!9 Me 104 Iq4 f
��ci y
Pity cical Address.Ce%,and Zip 21.
-
( Parcel idenailieation No(PIN) /.v 1
5b.Latitude and Longitude in degrees/minutes/seeouds or decimal degrees: 22.Certification:
(i:'wcll field,wu la:long is suffiesere)
! Satyrature of CeniSed 1t/eIl Contactor mu
6.Is(are)the well(s): dermaneat or OTemporary yy signing ihis faun,l hetvby cerl y Iha/the xe1l1.,j s<m'61'rny rnilrlratirrl IN rricrtnlrincr
1 With 1jrt iV('A('uK•.010a nr ISA At•A(•OR Q?11a;Veit('ruxtrnclnnt.Gaurlrtnb sun!than a
7.is this a repair to as existing well: Eyes or An cape u•/tira reenrd has hern provided In the it-ell ax•ner.
!1 thin ran a repair.All nr i katmw well crarsrnnvnm w/IroNon«n and aaplydn the nou're of the 23.repair mender::21 remark.•.tertian ar on the hack of this Pon y
n. you m diagram Or additional will details::
Yo may use the back ot'this page to provide aJdiuortal well site detail:;air\\veil'
S.Number of wells constructed: construction details You may also attach additional Pages if necessary
hbr midilph•nrle<vrnn fir«wo-i,nrerxupplr v elk OV..F uwk Ar Fame raar/raerkt a�tiu ran
2.t.Submittal Inatractious:
,uhtna«ry Jrrnr
9.Total well depot below land surface: , 1 5 {ft) 249. For AN Wells: Submit this form within 30 days of completion of well
I•irr«;nlup>le x:J'rhsi all drpilt.tl di/;teen;lenl«tplr•31@2501 MUIN11W) construction to the following
—
10.Static water level below top creasing T� (ft.) Division of Water Service
center,Raleigh,
Proeessitsg i,ait,
1I++arrr I;:rl r.rd+r+rr(,rar«}.«nr•• 1617�•iail$efviet Center,Raleigh,tC 27ti99-l61?
24b.For[ ieetion WAS: In addition to sending the form to the address m 24a
11.Borehole diameter: �T pia•)
``F/,r above, also submit a copy of this form vithin 3t7 days of eumolrtwt: of\urn
12.Well construction method: 8fa L construction to tine following.
is a ac�r..rul=y.cable.da ut push,nit.) Division of Rater Quality.Underground;nicedon Control Program,
j 13.FOR%tA?ER SE'PP2.Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276WI636
1 Pm 1 24c•Far Wiser Snoaly&fi1S terms;Wells: In addition to shin the form to
134.Yield(gpm) [ Method of test opy the addcess(!s) above, also submit am c of this form wnhin 30 days of
C��oYiY1P Atnouat completion of well construction to the county health deparimcm.of the county
13b.Disinfection type: where eorisuuctcd.
ke\+ses lax.2013
Forrt+G\Y-t
North Carolina Department of Envitaneneru and Natunii Rosouteea-Di,+sion of waxer Quality