GW1-2022-09340_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD
This form can be used for s togk or mrdGple wells For Iotetnal Use ONLY:
I.Well Contractor Information.
F
id.YVIiTERt4Es
Well ContraUor Namc FROM TO DpSCtt<pT[olY
P 0/ `rfL S'a ft
NC Well Contnuxor Certification Numl,cr f L f f toV ��
:15.tyTlTER.eASIAiG fornld.-clued'. tills ORI.ilYER'tfa licstile ..
82mette Well Drilling, Inc. ' FRO"' h TOm DLANjil jt : � ntATPRiAt
U ft in
Company Name -
. Y'6:'INIYEK Ci1�To SitVG Olit.TUBIXG
FROM thtinnal tlos��
2.Well Construction permit#: DIAMEIFA TIIIC[INFSg MATFRIAL
List all applicable i+rl1 construction permits�.e.County,S tq Troriance,etc)
ft ft in
3.Well Use(check well use): ft. in.
ater Supply Well: 1Z.SCR$EN'
FROM To 01AME1ER SLOTbIZE ESS OfATER
❑Agn THICKN 1At
ctdtural ❑MunicipallPublic• & ft ;n
❑Geothermal(Reating/Cooling Supply) DMidcritial Water Supply(single) in
❑Industrial/Commercial ❑Residential Water Supply(shared) AM.GRO
Olrri align FROM TO 6tATE[tLtI gM19ewC0NEM lyElpoD&AMOIJNT
Non-Water Supply Well: ft ft Nall Our
nt
CAipp
❑Monitoring ❑Recovery Q fc ft: L
Injection"cot: f
ft tt
❑Aquifer Recharge ❑Groundwater Reniediation
:SAIYDIGR4I;:Iza[t>1C `litile
❑Aquifer Storage and Rxoven tg
❑Salinity Barrier PROM To niArgRtAl
F1NPu�EM1tENf•.MET80D
❑Aquifer Test ❑StormwatcrUrainage it tZ
❑Experimental Technology ❑Subsidence Control ft. f
❑Geotttermal(Closed Loop) ❑Tracer 2U;11 ICI+tG`'1;UG:attaab: 38isdniif•shet£s.iiutcessa
❑Geothermal(Heating/Coolin Retum RROM TO DESCRIPTION rotor hardn soiproek .;-p
g ) ❑Othtx(e>grlainunder#21Remarks v ft: 3 ft
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4.Date Will(s)Completed: °941 � fk ft
p
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_ Well ID# �( I$N!
Sa.Well Location: T— R ft
FacthtylownarNanie R ft
Fadifity IDh(if dpplieable)
77
Physical Addtess.Gty,and Zip fk fG n is s
—tom t2 o+y —
Zl5 _..: ...:..:..:: .::.:
County Parcel Tdea0cationNo.
Sb.Latitude and Longitude in d �nptes/seco ; ^ r`' - ?z7 Unit
@Nvell field,anti Wong is ndsor deeirttail.i)egrce3 22.Cerfifiedtibil
W 6 D '� Z 2
ate
�ls fare)the wall(s): fte m-aueut. or ❑Tempot�ty §rgnat—.fctatufiw well Goo rant
Ay x4 ingAfs form,I hereby canny char the•wells)was(were)eonarruered in accordance 7.is this•arepair to an ezisting..well: ❑Yes or Me— "'rib'f3A�CO2C.OIOO or I3R NCrtC 02G.0200'TPtI(CvnsfrrtctlohStandordrarid ihut.a'Ythis is a repair f!l out known welt construction irformalion arrd• zO����!t!a0�har beat pmvided la the r eJl owner.
repair under371 remarks section or on he back o drlr�orm. n tTre nature ofihe
f. I 23.Site dtagftm or additfoualweU details:
You tnay'use die back Of this page to provide additiorraZ well.site details or well
For
Number of wells.r non-water
_ � bdnstnretion details. You may also.attaeh additional
For multiple injection ornon-rvarersupMY wells ONLY with the same co»aritt,rwl you can pages:if necessary.
submironejorm. SMI2'IiALINSTUCTIONS
9.Total•wr11 depth below land surface: �-. v
I'ormdliple we!(fitistolldepdasifdiffererrt(amnpTe_q�2f70'andi pp (ft} 24a. For Ail Wfiv 'Submit this to within 30 days of completion of well
CW 9 constiuetidotothefollowiitg:
10.Static water level below top of casing: Division of Water Quality,Information Processing Unit,
If>saterleve!lsabovecasing,use"+" (ft') Q ty+
16V Mail Sct•vice.Center;Raleigh,NC 276994617
11.Borehole diame'tec I
24b.For In!ecdon.Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also sitbrtrit a copy of this forini within 30 days of completion of well
(Lo.aage,mtaty,cable,direct push,eta) etmshui Lion to the following
FOR WATER SUPPLY WELLS ONLY- DWsiod of Water Quality,Undetgioand Injection Control Program,
1636,MWI Service Center,'Raleigh,NC 17699-1636
m) Method oftesk
13a.Yield(gp BIOVM20 111111111te 24c Ito!iV4tei Sun61v&Initxtioh Wei In addition to sending the form to
_
HTH ��� the addresses)Above,also submit one`copy of this foim within 30 days of
136.Dlsinfcction e: coin 1 ty epartment of the county
4'P flmourit p ehon of well construction to the coon health d
where constructed.
Fort OW-1 North Carolina De
partment of Euvitanrneut and Natural Resaueces-Division of Ware Quality� Revised Jan.2013