GW1-2022-07252_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORD
F II
This form can be used for single ar multiple wefts
1.Well Contractor Inffoor*mation:
���1 Jf LY.YQQ�� FR•Wa7'ERZOE�iES.
FROM TO DESCffiPTfO!
Well Contractor Name i Er. fr.
ft. fr.
NC'Well CoisaaeearCenifieanion\umber IS.OU.TER CASNG far wuEd cnsedwells DR LINER !fa )
�� t� �+ FROM TO DIAMETER c THIQLtiESS MATERAL f
@' t V- W21! Sri I l I nCA fr. fr. (14
f..'- 2t v
Compare Mari: 16.INNEA OR dserimlelaxd-lee
y Ot� � FROM TO D1AMtT:R ! TIdICK�ESS MATERIAL 1
1.Well Construction Permit M ft. ft. "? 1
/.rd allappb'cahlr Me1l cr,uarartian perm(/s h.e.C'ounny.State.I'orraic••.ere./
ft.
3.Well Use(check well toe): 17.SCREEN r
Water Supply Well: FRol6! TO DIAMETER -SLOTSItE THICIL14ES.S MATERIAL
CAgricultural 0Municipal/Public
00eothermal(Heating/Cooling Supply) 94esidentnal Water Supply(single) ft' fc. tit•
01ndustnaliCommert:ta! ❑Residential Water Supply(shared) 1&GROLFI
FROM 3a :1tATERAL 1­170IPLiACEM7,TMl:iROD 6 ANtOC'\T
1�lrragattun ft. fa '
Nou_Water Supply Well:
O'vtonitoring GRecoven g IL I
Injection Well:
[:Aquifer Recharge CGroundwiller Remediation 19..3ANDIGRAVEI,.1►ACK if ieairle '
To
CAquttar Stange and Recovery OSalinin Banter FROM. f<. !r MATERLtt E>tPLACt MEYf sterrtoa
r•
0Aquifer•test CStontnvater Drainage ft ft
❑Experenental Technology MSubsidence Control !
-TO—.DRILLING LOG attack additional sheets if neeassary
cGeothermal(Closed Loop) OTracer FaDM TO DESCRIMO,%, e ajar.hmdnest.soiflroek e.•rainsiu.etc.i
i=Geothermal(Hcatinz Coolme Return) GOsher(explain under 421 Remarks)
fL Er
ft. fL
4.Date Welt(s)Completed: ft.
S.Well Location:
F.-Cilh).0%une:Name l a ling 1D=ofalipliea le) ft. ft. _
T Ptee�l huh ('+� 21VPt e�d� fe. fL t vtalCNr��Ci
Pjysical Address.Cn�•a d Zip I I I r 21.RENMRKS'
K Vh
C ounu. Parcel ideittificatlon No(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
pfwcll field,unc latlong its suffieier:) `• f M+/1f b
/1�t1 n� Lll u�1/AY/
Si lure of Ccnified%Veil Contractor Dato
6.Is(are)the well(s): a4ermazent or OTemporary yy shining ihis•Ann•/hereby cerlt y that thi tiel/(.t�ear 61'rny rinacfrucled nr uectrnlumv
�J M•1111 15A NC'A('0?(-.0J0u a•15A N('AC 0-% 021111 weil anti thin a
7.Is this a repair to an existing well: ❑Y!s or \L'iVO wopt at tluv recwrd hag been&1wided in the met/owner.
l(tine r.,a repor.ll our krirnrn net/cruarrircaar tnfrarmarian and vxPlahl life nanre rip rhp
repair under;:2l remar9c.vecnan or an die hark of f/rh-k+rm: 23.Site diagram or additional well details:
` You may use the back of this page to provide additional well 8110 details or well y
8.Number of veils constructed:
construction details You may also attach additional pages ifnecessany
1•iir nurlrgile r+ilrCiran fir rrrun•M•r»c r.rapph•uefiv O;VI.I'1r11F,dir same 71mviraetiotl.You rail
,uha+il fin"•shun 24.Submittal Instructions:
9.Total well depth below land surface: �0�+ (ft.) 24a. For Al} Wells; Submit this form within 30 days of completion of tt•eil
hnr(ariinitle a eavloi all depiha if rG%lerenl ferrimpty-3• 1ill'ond?/ei IOU') construction to the following
10.Static water level below top of casing: 40 (ft.) Division of Water Quality,Information Processing Unit,
//Mar.-r h•:x t r.u>wi,•r,u..niF,n.,.•••/Q" 1617 I•la it Service Center,Raleigh,N- C 27699-1617
t 1.Borehole diameter. Ili ) (in.) 246.For I»ieetipa abk9i: In tddition to sending the fotni to tYe address in 2 i t -
above, also SUbrnit a copy of this form within 30 days of comDletiai of tvcll
12.Well construction method: �}11Qi'4f construction to the following.
ft a auger,rola:y.cable.dust push,ens.) Division of Water Quality.Underground Injection Control Program,
I3.FOR WATER SUPPLY WELLS O>�LY: 1636;Mail Service Center,Raleigh,NC 276".1636
I c t 24c.For Water Sttnniv&Geothermal Wells: In addition to scading the form to
13a.%'lend(bptn} h4ethod of test: +:(' �14'y� the address(es) above, also submit one copy of this form within 30 days of
f 13b.Disinfection type: F1�OY1Y1C_ Amount _ completion of well construction to the county health department of the county
where constructed.
Fomi OW.t Nanh caratina Department of Environment and Natural Resolves-Division of Water Quality Ret,sed Jar.2013