GW1-2022-03594_Well Construction - GW1_20220328

i
WELL CONSTRUCTION RECORD £
This form can be used for sinete or multiple well.,
).Well Cuotractor Information: n
�f 1'Y JT iQC�� 13.WATER ZONES
FROMI TO I DFSLRIPTIO\ �
Wall(bntmoor""ante i Et. ft.
Nt'Well Comractor Cenification Number IL OUTER CASING Mir mull- W webs R I.II4ER sfa
FROM TO DL M TBIQCYtsS MATERIAL
ft. fr. , - : ac v
Company Kmne }6.IPINER CASItkG 'dmr el
_ FROM TO DL►ME LR TNICKAFSS MATERIAL t
2.Well Construction Permit M wi)_ ft. ft. hL
I.at all appb'wlhle ncll wasiruciian perniks ir.r.C•ounn•,State,t'arianc.,elal ft ft. in. i
3.Well Use(check well use): 17.SCREEN
Witter Supply Well: FROM T DUhIETER SLOT 512E TAiCt4YESS rtATERtAt
OAgricultural Or4unicipa)/Public h• �• in.
y OGeothermal Featin Cooling Supply) fx. ft. in•
('. g/ o �Rosidential Water Supply(single) ,
j Olndusin FR
aliCommerclai ❑Residential Water Supply(shared) GROUT
FROM L To NiAT£RSAL iPLACEMEITMlTROD6A.tOl:\T
CSrrigatiun fi. OiG"ft- Y
Noll-Water Supply Well:
0\40nitoring 0-Recovery
Injection Well: ft. fL i
u^Aquiftr Recharge OGroundwitter Rcmediation F9..SANDIGRAtfEI.PACIf if irsblt
FROM TO MATERLIt EatPi,► E.Y'f alETftOD
CAquifer Storage and Recovery ❑Salinity Barrier ft ft
OAquiferTesi OStormwater Drainage ft.
GE>ptriinental Technology ❑Subsidence Control 20.DRILLI. G LOG aetseb additional sheen if necessary
Ocreathermai(Closed Loop) CiTracer FRn. TO DESCRIPTION coter.haidmusoilleeek Vne.-rain little.erc.1
CGeotherma! Heating Cooline Return) Cs Other lain under 021 Remarks) fa ft.
1rYlurlh �L ft. ft
3,Date Welt(s)Completed: ft. ft.
S.Well Location: fr. ft. 1
VQ 1�i�1.L. ft. fr. 22
F=14N.Uu tic-Name FacilirpID-(ifapplimble) ft. ft.
35�o No�l� Ell/ ors ft. ft. r`(, Irr
Pii 'cai Address.Ctt% nad Zip 21.REMARK
I(a33551
Cuxuu. Parcel Idexuilicatioa No (PIN)
Sb.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification:
(ii weil field,vile lulong is suffieuen:)
Signature nfCcnified Well Contractor Date
6.Is(are)the well(s): VYermaoent or OTemporary yy sinning this,larm./berrhp comfy/flat the u.ellfi)xw•itiveny rraavfraclyd to moire wkr
N71h i5A NC'AC'02C.010a m•15A 4C•,tt•02t ()!fill B'eii and thin a
7.Is this a repair to an existingwell: ❑Yes or Na w gs qJ this retard has harp provided hn the Kell ravaer.
Ii riM r1 w repw,.Ill nut k/aMW Wel/LTawfurn,ul Mformatxah and arpli'm Ilk•nature,!f/hp
repair under QI rc oarkv xeeitan ea'On rise hark of rbi s thrill. 23.Site diagram or additional well details:pag
You may use the back of this e to provide additlonal%wil site details or\\YII
8.Number of wells constructed: construction details You may sisu attach'addiuonal pages if necessary
l ur aa,/nple fivro as fir
nn•ivalerxn a rp/r e/I,ON].P n•uh the some camiraet(an.you tan <'r_•
24.Submittal lnstructioas:
,uhnia rune larm
9.Total well depth below land surface: _ 3 O V (ft.) 74a. For All Wells; Submit this form within 30 days of completion of well
For o duple 1,ANlixt all depth.,11 thllerenl te.vialph••3g201Y 01al1 a 10(f) i:onstrucuorl to the following
10.Static witter level below top of casing: 1 D 3 (ft.) Division of Water Quality,Information Processing Unit,
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1
11.Borehole diameter, Ig (in.) 24b. For I iettion. yens: in addition to sending.the form to the address m 24a
above, also submit a copy of this form within 30 days of x:omp)etwr of\sill
12.Well construction method: >Y� construction to tilt following.
(t a auger,rotary.cable.dsrca push,etc.)
Division of Water Quality,Underground Injection t:ontro!Program,
13.FOR WATER StTPPI.V WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
1 24e.For Water Snonly&Gtotbermal Wilts: In addaton to sending the form io
(3a.1'iefd QPMMethod of tear. �+sr �ta�.,
j (e'pm) the address(es) above, also submit oar copy of this form within 30 days of
13b.Disinfection type: Clntorine_ Amount completion of well construction to the county health department of the county
where constructed.
Form G W.i Knnh Carolina Department of environment and Natural Resouues-Division of Waxer Quality Re%ised Jar.2013