GW1-2022-10665_Well Construction - GW1_20221128

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WELL CONSTRUCTION RECORD(M-14 ForTnternai Use Only. ;.
1.Well Contractor Information:
J C,C1ML.C(%V�, c�S(Sl�l IdLWATERzaNEs +
1Vc!lCantractorNama Rolf TQ DESCRIPTIOiV
qo�3 - A o ft.
NCIVellConuactorCertificationNumber
33.OM=t:ASItVG(ibrmuhl•cased tvetts O$LIIVER(lr j
moil ITO DL6Rth'TEg !ffiCHteESS hiA11iR1AL
Company Name
16.I1MERCASING011- IIdG(eoffima dosedloo )
I Welt Glllsiruftion Perim ., 100 .2— W 5 0 FROM TO nrnn It 7MCBIw �u�T1;Rrdi.
Litt all applicable well consirnclion permits(i.e.VIC.Caalay.Stale,Variance,etc.) G I'. (p , Zs- in- S or z i PV L
3.Well Use(cheep well use): ft. ft. in.
Water Supply Well: 1T.3CREM
EBO.1 To DIA UMM SLOTSME TMCt01M h!ALERU
Agricultural 623'ide'lpitiai
" Tin.
Geolhonnal(HeatinglCooling Supply) WaterSupply(single) R• fL in_
lndustriailCommtxciat DResidential Water Supply(shared) Ig.GROUT'
itrl gtiQR FROM TO t+IATIIt4tL E4trLac fE�ThtEfAOB&Ahlotwr
Non-water Supply Well: ft.
Monitoring MI D--
[Aq
ion Well:
Ifer Recharge R R•
arg DGronndwaterRemediation
ifetStorage alai Recovery Salinl Barrier SAND!(iBAVEGPA hle
tY PXO]f TO MATR AL glPLACLrtffi.YT hiEr80D
iferTest 0Stomlwaterl)r&age ft. ILcrimental Technology Dgubsidenea Control tt. ft.thermal(Closed Loop) OTracer 26 DRIL MGLOG(attachaddFtlhcrtlwl(Hcatin kaolin Retrial) Other(ex lain under tl2lReularks) as Mown o�ta�:t:arane:ssoartatlt s�e,mrt
rc. ft. f a 6 bt c alert
4.Date Well(p)Completed: 0-a/7-ZZ wellM# `� tt: `¢qjr�• t-Gl c`
So.Well Location: n• R•
cfwn'SA
racility/d�me F-Hillyn7J!rifapplicable) R• [L i
c�kg L t Ne, a �q(,p
o �.v�e� I�°r �, S
PLyy,dicdAddress,Ci%audZ!p fr: rti.+
Y�-_ f7N�J1 !RivicP�3s4.., .-,..-, •.;1
j 1� 2L
COultty Parcel Identification No.(PINT)
3b.Latitude and longitude in degrees/minuteslsgrnndfor_ deFimal degrees:
(i4welineld,oneladlongSssntfieient) tANLI,lo�Q 't O 1,;�
22,Certification.
N W
6.Is(sre)the weli(s) a anent or E3Tempurarlr 9-MIU OfCORtfied Well Qulmctor Date
By stgtting tttir form.l hereby eetttfy that the tielt(s)um(mere)cartvsuc►ed in accordanre
7.Is this a repair to an wdsting well; Dyes or t? uith ISANCAC 02C.0100 or ISANCAC 02C.02a0 lVell Construction Standards add that a
lfthis is a repair,fnt our&nowt µetc camutrvetlon infonnadan and explain the nature of Me copy of thirrecord has heen provtded to fhe u e1t owner,
repairturder.421 remarks-section orotuliebacLofrhisfann. 23,Site di agrtua or additional well details:
8_Tor b'eoprohe/npT orClas¢d�cog[.teotfiedmi Walls bav:og the same You may use the baeit of this Page to provide addttronat well sIm demurs or wctl
GOMMuction,only I OW-1 la nccded,Indicate TOTALNEIMBER orwCUs a:onst6action detoHn.You amy*tsa*mach additional pnSes ifacaasaary.
drilled: ammi'i TAI iNcrttitrTtnl�c
9.Total well depot below land surface: 24g-For_Al Wells: SubMit this form within 30 days of completion of well
Fortnnh(pletrellstfstaltdeprhsifr&Jjerent(emmplc3a�a0'undZ@I00'}
�D construction to the following.!
IQ.Static water level eca below top of casing: (tt.) Divlsitna of Walter Resources,Information ProcessingUnit IftsarertecelisabarerosiRg,use"+� 251t7D?eit.Serviee Center,Raleigh,NC2769 r
II.BorehoIe diameter. �� (in.) 24b.For bdeetion Welts: Ia addition to sending the form to the address in 24a
12.Weil construction method:- above,also submit me copy of this form within 30 days of completion of weft
(.e-au&cr.Mtary,cabTr,fflrccrpusb, C.— I U constructlOII1ot$Cf0 OV9112.
FOR WATER SUPPLY WELLS ONLY: lllvisittaof Water BesonFa�s,Underground 1wecson Control Pr m
ogra ,
1636I all9e'f leCenter,Raleigh,NC276991636
132t Yield tgpm) Method of test; 1, .tl 24c.Ror 4V r Snnnly&In* ' 'A"' In addition to sending the form to
the addtt'ss(es) above, also'submit one copy of this form within 30 days of
I36.Disitl€ectiontype: nY� Amounte IGbi completion of VCR eonstrncl of to the county health department of the county
re whe constructed.