GW1-2022-06806_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD
Far Imuna![lse ONLY:
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1.Well Contractor Informa
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Welt cowmactorName Iv R AW lk I *-t fe
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NCWcUConaacOmrCcrdficafianNambv If'ODffiCGISIIVG far Iei eaweIIe OR311WEH
FROM 7O I DIAMETER lw� MUM"
CampanyNamc I&BOUMCA.SMORTUBIIVG ).
FROM I DIAM UM A IKKNIUM IMATERIAL
2.welt Constraetion Permir(I: 3 7 VOZ -f R 6� R t�" .5 uc-ill a {0 VC
LwaffoRII-M-ffp-n&re-a-*,,s�wolf=Igerraa�eta)
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3.well use(dtedcwa am): 17.St BEPa1
watersop*wem "am TO I DIAnlsres I IWWsM I MH[CraOss MA'[M ML
DAffieultmal 17munieipaVPnblie R d R " h 3,0 5 5
DGoodomal(SeatinWCooUggSupply) ORed-ventialWaterSLVpl9 R fc hL I.
MdusftkMCbmmevcid 9I a dcudd WhWSuppty(sb,,,,l) MCMUr
MtoM 10 liA'IFHW. EMeu MaM>:1soD&AMOMIF
Non-WaterSapply Well:-_ Q R fL hYep' C�;
DMonilcubg DRecovely
IDjeetion Wdk R R
OA4adbrRecge MmundvrrAcrRemedialion 19 SANDrGRAVELPACK d
FROM IM MATEMML i, 17APLACEDIMWMF3HOD
[]Aquifer Storage and Recavay Dsal®ty Basler R 2— R D bt
OAgwferTed OStorMwaberDMimge ILR
DExpedmental Technology USubddatce Cmdrol
-' �"ZDsDRII.LINGhOG addRiamisbeasif
DGeothamal(Closed Loop) OTlacer FROM To D17C17oN CgIm son M* saGac.
13Gseot ennal(FIeatmd/Coolmg Relum) []O[her(ewlain tmdw#21 Remarks) v R Zd R --1'0
12
4.Date Wd1(s)Completed: -f 6-ZZWdl HW 20 R - 0 R �K24G. `lam M t2
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(dwenfald,aoelatlloagissuSeimt) ! i 71U)j pp(iC�. ii 1G li�i
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sigoaaneofCa6fiedwcIlCmtracmr Date
6.Is(are)thetvsll(sX GC ielthaanent Or []Temporary gysigtf g dgsjbm I hem by ca*tlxa ncc a d!(s)urn(ram cm r mmd w aaewdm w
- - vt&ISR KCAC 02C.0I00 or ISA PCAC 62C-OZW Weff Canstraaron Stm nlv&and that a
7.Is thin a rep2h tome eaistmgwd@ Dyes or acpy ofdtirr morel h�bempmvfded m thewell oimer
Ifther is a npalr,fell oat bm�m xe/I a�sarrMmn itfmmatlon mrd esp/aFn the rmaoe of the
tepafrrmder�2l nemmirsemmtoran thebadrofthlsform 23.Site diagram oraddhfioual wetldetar7s
You may use the back of this page to provide well site detahls or well
8.Number ofvte&eonstmcte: I conshuction detals You may alsv attach aWitkmi pages ifneoessmy-
Form0pleAvkahwarnan-u%mrsippryadkOALYwandwsame a�Pmcan
=hm tMx fOnM -I SUBMITYAL EMUCTIONS
9 Totalwell depth belowland surfer r/�i (fk) 24a For AN We1[v: Submit this fo m within 30 days of completion of well
Fornmfapleuv&fin affdgAF#W u(--Wle-3@200'md2QIW) congnictiontothefollowiog: j
i
10.Static water level belaw top ofeasDhg: 39 (R) DivtdonofWatwResouYce%h&rmad=Pmcessi gUnto
Ifwaarfevel isobmeaadng roe^�^ 1617 Man Service Ce�Ral igh�NC27699-1617
1l.Borehole diameter. I` hn.) 24b.For Infection Wells ONLY: lit addition to sending the fomh to d o address in
f
24aabove,also submit a copy of diiS#funn within 30 days of completion of well
12.Well construction memod: r&Lila cmukuction to the following: fh
(Le--a-.rotary,calkdiradpasb,cte)
Division of WaterResomees,Undagmand lujecfion Conhvl ProgrAin,
FOR WATER SUPPLY WELTS ONLY: 1636 Mal Service Cer tt4 RddgL,NC27099-1636
On.Ydd(gpm) dS Math"oft+esh AOM%
24c.For Water Snpplg&lniecfion Wells:
pll�� ' I Also submit one copy of this foam`within 30 daysofcompletionof
13b.Disinfection type. Amount to the county heaUhj depuimeat of the oo®ty wham
coustnictedL
EamsGW l NaAhCmofmal?gmemmtofEnvuanmrut=dN=aalRemm=-Diviw=arWarer ,I RevisedAoeosr2013