GW1--07416_Well Construction - GW1_20231117

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WELL•COPTSa'RUC'1'ION RECORD(GVIKA
• - :. . . ._ _ ) For Intenial Vs!Only: ' •
I.VI,ell Contractor Info:Marion: • .
David Belcher -
Wall OontnctorN�e 11.WATEB ZONES .• '. 1 I.
• :. .. FROM TO DEfiCRIPrRIN •.. _ _
4•54..4-A :59©Q -_-5�t t` ( • .
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NC grail ContiaetorGbrtlfwliuf Naaibnr f '.. .. • 1
_Aqua OM Inc. • '
OUTER a
comp�eyldame.. - .. - .. • .. . ,•. .�� .•�� � a.•I- � Q ��nlAtwaw)METER OR �•
19 Of .. . ;
TRIMNESS • MATERIAL.
INNS _
c'a G.�� -OR A::
FR S f1OE1�DIAMEPtothQlmilalcriddolA) '
2:W . CotutructtouPermit#t' . '� �'
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Lldta sPpZ1cablewllcon clop FROM°" 7n DIA6�YYR _'7HIC�NE69 MATERiA4 _ ,. . '
promos ge.,UIC,:Caunt Smug'Varlanee,4110•'' - .- • - - 3G •:,tLt. .. ; lo,
. .3.Well Dee(eheek Well use): •:•
Wate Supply
37.SCREENi
p�Caitntal 'FROM" TO DIAMETER• RLOTSIFE• THICRN89s MATERIAL
I• 'i' pal/Publio . . n. • - . - .. -
t � (HeatinglCcoliag Supply) 1 i'Residential Water Supply(single) '. - .
I ladUsldal/Coaanerolel re •
identiel_ •I � Water Supply(ems): .
• Irrigation iR GR017T'
Nonigation • : FROM • TOE - - MATERIAL., • ;E:MIPLACEMENTNIETRODdiAMDUtilT
uPPl9 Well: • � �. t n
: ■•Mo itore. . .. • ,C,i. •:f - I- flL t4l}Irlinr4e : Vat—I-. e'114)5 4. .W dr. f'P
eetlan Wells �Recogery
aS AquiferRecheig •a
` �Grru:nd a atar Reilediation •
•: .. & .:..•. ,. . .- '..� •I' .
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' • '19.DANDWGRAVRLPACSBI.Alleable) • .III i Sf0lageg����Y 3ain.-.. le • ' FROM
qu,fer Test •m' E3Stosmvuater oietnago ::: 'iG .•. :- :: rtne.: : .
:sal`Bxpei*fiil Tealmology':.. .•, EISub9ldence Control :'-
:IS Geothermal(Closed.Loop)- • D4)aa '• - •: . 20;DRILLING LOG Canada additional'theta fr eary);
Geothennnl( tblg/COo Realm .. . . .FROM. . TO • • .'DEECIUPTITIfe er.nadnw.enlUroeatseemiln.eteGele.)
>� ) Other(expleiuundea#21-Remadcs) .. . '
4:Da Well(s)Completedt i 1•'�.� . ' �'
WellD1P ' . ' •'. .• . o. Sell I.S�nrJ
Se.Weil Lacetleet
71 aLi '�ailA ran
�ih'1 L•©Cnt n.' . . '' :
racilib'/ Name
�°'�'' FaciRlYmouteppllcable) . f* . . ... Fr p. y.
la'751: '.IULJY )(o ' 1 /1c... :_4;1j we r1 41W . . • .6_ fti: NOVA "- • • . .
• Ska1' ;CO,andZip : -) •: to • �- 1 / 2n?�
• . • • idol1. . • • 21.RSMARKIi �r
twiny1. Patel idiimitissilmbrii.(Pen • • -
Sb:Latitude and longitude in ..• -
(ifwelttkld;one Ihtllong n degngeslminuteshleaonds or dedoial dt�eea<: ' - - �. .._ ,. .. • - _ -- . ,
suPaient) . . • - .
��t)��-�a• �.�,� .2Z.,1'erfl_BCatlen.. • _• -
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.�iTr � . :
O.Is(„ )the wells) . Permanent •or" - Tem D 1` - a3.• .
• � P � � Slg®tu;eofCertitled ell.Conttactor, `�. . ' • . - • ' Doe. .. • .
• By signinglbIs;Am,I hireby ctie that Ilse Mullis)was(wen)•conatnmled in accordance
7.1.Oils a repair to 4n existingwelb Hes or o • with ISA NCAC 02C:0100 or ISA Nate 020.oa00 Well Contfruc1 Slmrd, and theta ' '
ligh tra repair,fill mitlarowo wagcontHadlon fq/ormatlea aid arplo/ntFieaogovgJ7he - . capyoJlhlsl+ecordhcsbaeaprouidedtothciuelluwner.Opal?urrdar#21.ri nark.secganorontbebaekethtsibtm, • • • -
S:Foi eo '. - .23.0 site di® or additional well details: . • . •, . -
. . gram
oprobe/DPT or G9osed.Loop Geothermal We49 hayin the same• Y may use the back of this to
S P� pmvide additional weli:site details or well coastal:100n;only 1 aW-I is needed. Indicate.TOTAL NUMBER uflit&•. . :• construction details. You amp also additional pages if necessary.
drilled:� - .. � . ;• '
pUBMrrrAL INSTRuCTiONSI
9:Totrilwuell depth below land emlace: 4i' . . 1 .
Forawlt lewelisIlstalI&SO(J•d[Bpent(arample=9Q200'apd2Q1009 ' .. (ft 9Aa.JP1or AU Wefts Submit this.fonn.within 30 days of completion•of well
' canetmotioa to the follwing: i
• - llL Ski c writer level below top of casing: Lin '• (ft,) • . Di•vision of Water Rem
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!jtiwtcrl`wlb do*oaths we a+.^ ttrces,lintornahtaaProceifing Unit,
1637 Mail Service Center,RaWWgh,NC,27699-1617'
li.Borehole dipmeter: .: : (a{ ;Su.)�t 24b.,For'Inlecioa Wells:_In addition to sending the form'to the address in 24a
• 12.Welconstrictionraethodr -•lAt+l AO above,:aka submit one copy-Of this foot within 30 days;of completion of wall.
(Le.auyi assn.?.cable,directpusb,elo,) construction to the following f i
• FOR W'TER SUPPLY WELLS ONLY: Division of Water Resources,lndergronad Injection Control Program,
1636 Mail Service Genital,Raleigh,NC a7699-1636
lie.Yl. d(gpnd 4 • • Method of teits-Crt telR.4'`'1':1bp 24c.For Water Sabnly&Infection Wells: In addition to sending the.fmm to .
t) the address(es)above,-also submit one copy of.thistorn within 30 .of
13b.Dielnfecfiuntype: 147N �0/n dt4Yu
•
.AmonnC• 'ftntJZ .-. • completion of well eonstrnodan to the county.health department of the cmmty.
_ whole constructed.
FonnilW.I NorthCmelmaPoparfaion;ofEnvimpmentat duality-Divistoa ofWatarRoommate
Rooked 2-22 2016