GW1-2022-03597_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD F
This form can W usod for single or muttipie welts
I.wen Cuntraetor information:
;s r �'sreet)Q F—Rom ER
� To DFS[RtP'Ro�[
Welt Contractor Vsid tie ft. I j
z i
h, ft,
xc Well Contractor Ceitificalion Number 1UMLE o
Nor ivetb flleF!EM a MA7V"L r
fR K TO D
• r
_ ` earl.n�titr�Ii
Compam \arm TaFSS Trt t
M DtAat RIAL
2 well Construction Perruit 0:
l.t..l all appkWhir urll erwxlraclitm permits(i.e.f'aurl{r,stole,Mono"-emi ft. ft. in. j
3.Well Lase(cheek well use): t7.5G1tEEN
\Water Supply Well: T D let in. SLOTSQ TNtCKN&M MATERIAL
1-1
�Aericulturai GI►4uaicipal/Public ft. fir
11 � ft. ft in.
OGeotherinal(Feating/Caaling Supply) 96 idefceteal Water Supply(single)
38
MIndustnaliCommerc[ai t7Residential Water Supply(shared) MROLFI
To MA PtACV4 T. &AM0UNr
^Irrigation ft. '��"fa m1x r
i Nou-"'rter Supply Well:
+
G'vlonitorcng GRecovery
Injection Well: ft. ft 1
[:Aqucfer Recharge ❑Groundwater Remediat[on 39..SAlVD1oG PACfC if
i FROM TO MATERIAL E?tPt.► GYrStE7HOD
CAquiter Storage and Recovery OSalinity Barrier ft ft,
�Aquifer'1'rst C3Stormwater Drainage h. ft.
0Eaperkiiental Technology MSubsidence Control Zg DRtLLI*IG 3.OG attrmh addidoaal sheets ifesr�srarr
=Geothcrmal(Closed Loop) OTmedr hat;lnesu sommelt ryem vain Sim.tic.)
CGcotliernial( InVC001ins Return) COdter lain under 021 Remarks) TM fe
ft fL .e
nr h 10 t
3.Date well(s)Completed: �„y ft. fc.
S.Well lon/cation: ft. fee !
F=F%%.pene:Male Ofapplieable) fL fl. facle
ft. fL
901-164
Pi i A1, ress.Ca),nad Zi
l,-�. 2,1.R
C'owity Pit" ttkntificatiatNo(PIN) -
Sb.Latitude and Longitude in degreesiminuteslseconds or deeitaat degrees: 22.Certification:
(+:'e�cll field,unc iatlong If sufficient) —
4,,,,,1�� Segmture of Certified Well Contractor Datc
6.is(are)the wel)(s): ertasnent or OTemporary /)p xl1,t+11trg 1hts,jonn,I llrroh}•Cal,14 lhul the uef/(.�/was 6reA')rnuelradlelt nl utcnnlurkc
with 19A Nf'Af t*'.O/Oa nr 13A.feet'ON' r1;Qu lVeil C'nnrtrrrurrur.4ourlr+nit+end that u
'i.is this a repair to an existing well: Oyes or 941 o uupo uJ ties redrwd has Atria prrwidrd m the urll nx•ner.
rctr'rillt.,,,repair.
�l rclle k.,e w Weav ll
ten the hack of ix born and vxplafn the ava"ee til the
23.Site diagram or additional wet)details:
' You may use the back of this page to provide additional%wit Site details or wroii'
S.Number of w'elis constructed: construction details You may also attach additional paces if necessary _
Fur unrinpie tnlernrn nr naa•ntNrr.rupplt vial/s ONi.1'w1h the some;;;iW_Ncd6at,}eta eo11
uhnut am fnnn t 1 24.Submittal Instructions:
9.Total well depth below)and surface: 1 /lD 5 {ft.) Zia. For An Submit this fitrnt within 30 days of completion of hell
tier o:i4ml+le ew/Aheoil depth..ifdrllerent feratapM•3-1Hui'mul267211dr) construction to the following
r
la._Static water level below top of Iasi ��O Aft.) Division of Water ce ceri,r,Ralufat'leigi, Processing Unit,
_ _ �� _ —_-- _.__-,- _ 1617 vlafi-¢ee�ice_Senxr,-.;tateigh,�G 27699-t6t7
lhru+rr Iv•rl r.uhr+ere u..u+tt.rr.,c.. .. _ - -
1 24b.Fer Injection_weft: In addition to sending the form to the address of 2.iu
t 1.Borehole diameter. ('dn.)
above, also submit a copy of this form within 30 days of cunepktioc: of eve))
12.Well construction method: tSQr construction to the following.
1[a augcr.rain.,•.cable.dire:[push,etc.) Division of Water Quality.L;ader;round Injection Control Program,
13.FOR WATER SL'PPLI'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
i 13a.1'icid(91201) 26e r .F•�yater Snoniv (,eotlxrttaal Wells: In addition to wading the form to
Method of test the address(es) above, also submit one copy of this form within 30 days of
Aawnat•._ Completion of well construction tothe Bounty health depairtment of the count♦•
136.Disinfection type: where Constructed.
Fomi Gw•t \dnh Carolina Department of envirozinww and Nattiest Resoteraa-Division of Wiser Quatity Re.ised lay.20 11