GW1-2022-09925_Well Construction - GW1_20221031

��qi6 d{0't�ILy.
WELL,CONSTIIUCTION For Internal Use Only:
1.Well Contmetor Intbr matron: _
runt naascttm rtaxv
Well Coctraeta Nun --- -
_ rya 9ft. IL
3 iz ft.
NC WeA Cacaractor Certification Number -- --
MOMCAfid1YDNorat LMloft
/ a t f� /f FROM TO DIADMIaR TH1CKNM MATERIAL
Cotrtpaw Name
�7 i1t ��
2.well Conah'aed"Putt 1:-A ; -6� 176 vteonr TO AtAhur�t TEM00QW NIATEWAL
last all applicable w W cowirurdan pea odes(l.e.lJ1C,Conroy.Skate.Panowe,eu.) R 1t. is
3.well Use(cheek well use): fL ,It. in.
F
y well: 17•tseoM To DIAN SL)T UM TAIL! 0Munico /lrublic fL t• is.
(lleating/Cooling Supply) residential Water Supply(single) rs ILommarciai Residential Watter Supply(sbared) TO MATZAIAL &WLACLnt M M97WD A AMOUNT
Non-Wafr Snpply well:
Monitoring ORecoveiy f it.
boveftn wa. tt tit
E
charge OCaotmdwater Remediation �, - ?f t,
rage and Recovery [3Salinity Barrier t ROM _ TO MATBAIAI EMPLACLME14T METHOD_
t n5tormwater Drainage �•
Experimental Technology �Subriidence Control 1t. i
(Closed Loop) .Tracer 2D tiiQHI 1d[VG - suaeh addid It'ao rrgl.
lnng'ltearin) [�l?dier(ex�la n under#21 ttesisarin - � - IL
4..Date Wd4s)CoVlebed-J , 46, wen IDO/
��.wit ®�•_ fa, ft..
tom-t
FacilityrOwnacr Nomef Fxtlity�IDq/(if epp/l� k) t/.
Lr! wdGe� V' jrry
Phyaiod `City.and Zip . _ _ it, --•- �
Qdmty Pared kleutifiration No.(PIN) _ C.ANQjQ*3O _
Sit.Latkude ants lcq tudt to degrets/minates/seconds or decimal degrees: --- - -_
(if well f eld,Oct lat/bag ti euffieiam)' 22.Certification;
6.LKare)the weD(e) Permanent or [3Ttmporar7 Sig uture of CertiW Well'Contractor Date
By signing this form,!k—by cerhA dw the welt(s)was(were)coaseructed in accandorce
7.Is this a repair to an erlstlag well: "�Yra oeto wetk..15A 11CAC 42C 0100 or I SA A'CAC 01C.6240 Well Consatiecnon Standareir and that a
tihis&a rrpmr Jul out brown well construtikm b�orraation and ZI-in the nature of the copy of Ak t ecor d has t ren prgvidKal to the wosl!owner.
rrdwer uetkr 011 reeanb section or on the back of ddsform.
23.Site diagram or additionsl well datal8a:
8.For Geoprobe/DPT or Closed-Loop Geothermal wells having the same You may use the back-of this page to pm- vide additional well site details or well
construction,only is needed. Indicate TOTAL,IVL'MBER of wets
construction details. You may also attach additional pages if necessary.
drilled:_ //�( /� 5114IA�' Sl1CTlONS
9.Take!Weil dep*below hand surface: / �,l (B) 2da. Eor All 9'e'tlia: Submit this farm within 30 days of c onipleiran of well
For ua datple*w&lice al!dggb Vd*reru(evanWk-$@240'and 1@(44') conshuc:tion to tite following:
10.FoWtk water level below top of ragtag: (ft.) ixvlwac of water Resoarbes,ioformntiou Proeendng Unit,,
-if VVk1r level is above carp%acre"� 1617 l E&H St eviee Center;Rah:lgh;NC 276991617
I1.18orohobtA dlanaotas: 24b.]For Infee to sending the form io a address in 24a
above also subroit one copy of thislform Aithin 30 da.. ys of completion-of well
12.Well construction method: constr=tion to the toilowing:
fix,ewer,rotary,eabb,'dbw poa14 etc.! -
M Division of water Retources,Uidergronmd Injection Contact PyWam,
FOR WATER Si1TPlt.Y WELLS ONLY: 1636 Mall Servicie Center,Rslatgh,NC 27699-1636
13s.Yield(Vm) Method of teat: A19 24c.For Water litiection grjh: In addition to sending the forth to
the addresses) aborrc• ntso 9ubrait one copy of this form within 30 L days of
Yob:l Idnfmdon typeC' Amount: completiou of well construction to she county health department of the county
• where consuucted.
4*artn CtW-r North Crsohha rmpartmeat of Envirotmeental Qurlity,-DivW=of Witei R&x ur= Revised 2-22-2016