GW1--04269_Well Construction - GW1_20240719

1,viv.11 contractor lnfarmarwn:
Robert Teague 14.SLATER wIm
ze�-C--1
2857-A
NC Wei cww UTERCASING far amid-caawwdit EX
FROM To DIAMETER 1p Nr-" M'T1R1AL
8&K Well Drilling Inc M SUR-21 PVC
Cot my Nmr�e1 16.INNLR CAS6413 OR TURING
I Mom 1 TO ER L
2,win consiTuetw.P"'.if if: I -R. _T- I "'-ESS ',"*T IA
0c,C­"Y'sr�" f
in.
ell Vat(rherk well ast):
W*trrSapp!y`A'tN; - 11 FRO.1 1 10 DIAMETER SI MATERIAL
A�nCultunt �MunioipaUPublic ft. to
IR
cfWaIermal('"MongCoohrij Suppiy) oResidenual Water Supply(single) f.L ft In.
(3Residerinal W3ter,',upply fsh,]aved)
I&GROUT
FROM TO i MATERIAL FM PLACT.VIT NT y!El HOD&AMOUNT
Non-1411it"Supply Well:
J-
M(mitenng r3licco'cry n. M
i
OGmundwatcr RcmCd1aum
feagtora J Recovv) []Sahniry Barrier 19.&ANWGRAVEL PACK(ff*0vJ!c*W,)
0storinwister Drain N!O TO MATERIAL EMPLACEMENT METHOD
Aquifer Drainage
hoology 13Subsidence Control ft.
LOOP) OTracer 29.DRILLING LOG attach addidocut]theeb If nnES&W
Geothwinal(HeigingCooling Return) rJOthOr(Cittilain under V21 Pemanksj s'uom To DF-SCRI F1 IOnt r.h*rds DVr�k!�-6 a-1. k-
4-Date Weiho cowplettd:c- 5--�q "eliffm
Sa Wa Locabow
ility Mfs ft.
Den vc K ft. ii.
ft. ft.
ZL REMARKS
Pat l Tdcf,fivi,n No.(Pf\)
56*L4dtudr and longitude in deVve3/n1mUtWseconds or decimal degrees:
EZ4 ox 4t ff
"jo"a� 'j'n'4
22,Certifii:2
N
6.IS(&")the W'ejJ(r')0P11ntn1 or [)Ternporan signature Or Cemficd Well Con zor
Date
7*14 all$0 repair to an exiisting wen; By xig>ttng this
h""6' ,,,jjy Thal the
�o - 4 15ANC4C 02C-0100 or JJA NCAC QC.0200 Well C,nsrmctjon Stod,,ds and that
7Wallfill OVIAm" he6.ck ,A4Tfo, YftLe 4 the cOPY 00441 record has tw,,p,,.jtrd a he ell Oj�
t? For Gino 23,Site diagram or additional well details:
prvb"PT or cjo'ed.Loop Geothermal WEDS having the same YOU May use the back of this Page to Provide additional well site details
co"tt'"TIOIL-)Y I GW-1 js needed. indicate TOTAL NUMBER of,,,,,
'/� — construction details. YOU may also attach additional pages jfM,,,ay. or well
dTsfietf: 'low jaind surface: &OMITIAL INSTROCTIQNS
0
24a. Fot All Wells: submit this form Within 30 days of completion of
'0'St2tIc wafer level below top at cuifilz.,40 construction to the following: well
(ft.) DiVision of Water Resources,InOrInStion Processing Unit,
11,84rchOle ditn*tt,, 6 1/8 1617 Mail S I
Service Center,110eigh,NC 27699-161-t
12-Well corstUruction Air Rotary 24b,
Eo�"tln trice-won in addition to S�nding the form to the d
c4bie'a �'60%'c� also Submit one copy of this 4 drts6 24a
Form Within 30 day
construction to the following� s of ct)m
FOR WATER 8 Pletion of well
UPPLY WELD.`
Dlv'$'Ofl Of Water Resources,Underground lnjectiOu Coutrol Program.
'Vm)
1636 Mail Si�Icthod or Air Flow Service Center,RAltigh,NC 276"wIW
136,DbWeetioa type, Chior Tabs 24-c.
1 V2 LZ5 the
7ss(cs) above, ]so in!ction e af�Stibmit [11 adcht�Ori to scodiag the form to
aompletfon
of this form wfthin 30 days of
where cOnStror well corstrUction tL) the
co""t'
Icted Y beilith dePantrient of the county
...........