WI0100674_Well Construction Record(s) (GW-1)_20240116

WELL CONSTRUCTION RECORD
QW'1 For Internal Use Only_
1•Nell Contractor lnformntion:
id.E'bATER ZONES
tiYellContractorIv'umc FROM TO DESCRIPT1UiV
V Q Tl It. ft.
NC ltta]I Coutr"lor,
ClInif-tinn Number ft.
L 11 �D is.0I CASIIVG tier mutd•cawd wefbs fl8LTNM gr annurnate)
Y\C- EAOi[ D aDiM htATHRiAL
eonwany Nametk. ft. in.
1.WollCmtruchonPeEmitp U UO(�"-1 Fl(pS �CAStrl°OR�ub tat cothermaclosed-loo )
bl tt uli agnftcaLte aril conSlnrclion To UiAM1it3[Eit 7MMI�IESS ktATERIAL
Ikrmtrs(r.e.UIC,Camay.glare.Yarimrre,rrc.) ()ft. h, USX Z in, ISM f I H Dp E
3.1Yell Use(checK well use);
ft. ft. x at
Water Supply Well: 17.SCIiEEPi
Agricultural
Gcaihcrmnl Mun(cipalPublic ft, TO Ft. DIAinR. S "NE
(HeatinglCog Supply) DResidealial Warersupply(Single) Y H > htAlEtr(�,
f ,IndustriallCorumcnciai in_ _ f
Residential Water Supply(sh ut;d) ft. tt_
riFTi alien IS.GROUT
Non-/'YaterSupplIu Well: FRONT TO btATERIAL ENIPLACENM%rRiEiHOD&Ah(OLhi
m0aitorin-4 tj ORccovcry O ft. �{I .
F>ajectioa Weli; rt. ft. I I�
Aquifer it arga DGmundwater Remediation R' f r-
LLaigotb=rd
rrgcanr(tZccovory �Salinityg � 19.Se;N11/G1L4VE�PAC$((f b(r
TvQlStormwatcrDrair(age ft, g,al Technology DSubsidcncc Control(CIosW Loop) 2,4 D(Huatin /Coulia Return) QOther(ex l Lin under:t?1 Rernad s) O;t T° DESt UPTIaai fm(m•-tr �,11fm
ft. ft.
4.Date Weft Completed:��3 Well 11Dff
5a.Well Location: °
1�L«�SA V ^ vi Al T1 1 r t.�hu5 ft. ft.
7acAityf0wuer Nn c Facility TAG(rFapplicable) ft ft_
3010 b•-oad VtiSEa Lh F1S4�e ��. ��ir Y Spy r:. fr.
Physic-al Address,Cuy,and Zip
1Lll V'\-C� .Q �')7a1S ?y�000an n' I►satuss
County ParcelIdClI fcalion;Yo.(PIRA—'
5b.Latitt(de and longitude in degreesinlinutedseconds or decimal degrees:
(if well Ileld,one]ar/ .is saEficirnc)
12.Cerriflcntion:
5° 3°►t �1 `1 ga'' ga°3l ' 111`L W
6.1s(are)the well(s) ermnnent or [3Temparary Signature fo Cc •in fled WCII Contractor
Dale
7.Is this a repair to an eldsting well. By
of By sill llrfs foml,f hereby rerrify thor 11re rrelljsJ tress(sere)corrrrrurrEd in accordance
O rsilk 5ANG(COZC91o0orlSAVCACOZC,OZ00;reel,Ca 1 c'
)jrlJr it a repair,Jill our fniay.ryc•velr convruUinn inforniutiorx and erpfain d e rwrure of the co1jy of tlusrecord has been provided l0 The+veil Diener_ bon Standards and chat a
rerrair under 021 remarks section or oa the track of lhisfornr.
23.Site diagram or additional weH details:
8_Tar Llion helU177 nr Ctos¢d-E oop CeoflieOTA Walls(,caving rlrc same you may Use the bRCIC of this P980 10 prouide nddition d well rice dccairs yr rvrrl
construction,on1 1 fsVY-t is a dcd, Indicam TOTAL l ti3irlg>;g of wells coavmedon dotmU- You may o(so artnchadditional pn&os iF,l"&cfl
drilled: 1S0 � `
9.Total well depth below land surface: (�.)
Formulrfple�celtstisrafldeprfuijdifjtrrnt(example-3@200'arrd2a 09) tea•Fer All Wells: Subtni! this farlY(within 30 days of completion of Well
construction to the following.
10.Static l is above
level below top of casing.. (ft.) Dlvlsion of Water Resources,Information Pmc ,
If nvrer repel is above casing,use'4^ erring Lmt,
ll.l3ob'ehole diameter: to (in-)
2617 Mail Service Center,Raleigh,NC 27699-1617
Iflie
2db.l or etion Walla: In addition to sending the form to the addirss In 24a
M Well constr wdon method: above,also submit one Copy of this form,Within 30 days of completion of well
(i.e.auger,rotary,rabic,(irm push,aL) ---- COnSErucllon 10 fbG I OlIONlilg:
FOR WATER SUPPLY WELLS ONLY: l)IVWOn0FWater�urces,Underground1636 j�jection Centro!Program,
e` ue CMt'er,Raleigh,NC 276994636
13a,Xield(gpm) Method of test: 24c.For Simoly&Inie�ti 4rJel
In l to form w
thi adtlmss to
t3b.Disinfecfion tvpe: (CS) above, also Submit one copy of addil
it�a D e lays of
AmQt tl completion of well Construction to the co
where constructed. uluy heclldt dapartment of the county