HomeMy WebLinkAboutWELL-07-2015-062773 MEM 02/26/201E 15: 30 7043924705 EKWELLDRILLING PAGE 01
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W'EL CONSTRUCTION RECORD C_1 9,1Ed i a 41/ (,
This form can be used for single ce mukmk wells I roc Internal Ilse ONLY:
I.Well Contractor Information:
Robert E Teague L.w,.rs —mss
well Contractor tame ��fra OM r TO i atSC0.1YnON
C rt. f' 6 it I /
2857-A 5 n ,..,
NC Well CO/:actor Cmifio thin Number 171 // e",
'L<.p6TEaGAINt4forma+nca kAM41c>ak:INE* t ,
B 8. K Well Drilling Inc. 'a-z�_TM, 1 mA�MtTFf TP$]KN sS MATERIAL
Company Nuve — 0 D. I h. I E 1/6 SOR 21
PVC
2.Well Construction Permit n: 6 n :2 7 I s-Ro + r To _ TI nAMETEn T qA' tLko1 MAT:eR1
rat
7,70 all apabtaSft r/1 iniirvatlon rennin,.ii.e. n r . va ; ; ei.. _. — ft ) )
In. I
3.Well l: ft f I in. it
Ose(check well use
Water Supply Well: Fepar i Tn
irarc
__'milt
'- a2E I tocKNF3} , NAtrnt Al❑ggncuimfal Cc unicipal/Public n.
j� d:ocanallkeating/Cooling Supply) L7Rcsidenu of Water Supply( l 1 K n.
, I
Olndus'trial/Commercial C)R.Sidcntinl Walcr 9rpply(;hared) 't%GAUT2F " •n r'I.;I
Oh&ation (ROOM TO MATCNIAI CMPLACeMtAT METyOD S AMOUNT' I
Non-Water Supply Well; ---- 0 _ n. 20 ft. !Hole Plug Pour/Hydrate
❑Monitoring -Ruu c7 ~f. ft. I
Injection Well: ft fr { ____` ""-
1]Aquifer Recharge
_ [IC.oun.lwa[c' Remediahan !79:16'1R'/M.Bt.gy�LR.1CKiSapyDtnb/c] •'.t,:r.
Oqd nhr St raer and Recovery ❑Sidinity Harrier 1!cis' It_ MATTR1AL
tT —� Mr L6FMNF MFTNOn
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DAqu.fcr Tez EISItlrm dater IOramay,
❑Experimental Technology ❑Subsidence f orteol ! �[e ._..... —_-
O(se0tlicrmal(Closed Loop) [-grocer
h7—. jjfaBaLL1NCO e1fC, nitaCi ddlenisn♦I,hiendkr•rNcesairy}r ?: ,1;.71
� �_ 1 Ul1SCmer ON rolr.han),TiLirock ripe.pi �,tic)
°Geothermal(Heating/Cooling Return) ❑Other(explain under 721 Remarks) n_ j ) ft. i (y 1 er.
4,Date Well(S)COmPletLd-�2 a ,6 V ell Da .L I J a .. --S R
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Sty/fell Well Location: cYW �Il_C� IA (r'
y p/�'� I f ��/fI y��/ h. h.
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Foeiiy(hvna Name 'n:iiry:Ds(ii eoldi:ablel — .,._.__
h n r
Physical Address.Cit ,and Zip
County Parcendcnrif nror,Ne
(PfN) 1.-- —
Sh.Latitude and Longitude in degreeaiminutesfsee owls U.decimal degrees: Ficarlo _
filuellfieldeneln/I �fhciuv) 22:' l
N W -_-_ �_...~)-A
1 Ycsnee t .e Ti Well C' u-.frto Dat-
6.Is(are)the well(s): 1Permanent or O'Tempontry
t rr Mrs'fin, I Inireby circify that iha nall<c) nos (nova) •onn+w;red in atto dome
h IAN A I r.( 0700 nr 15,9 v q '112C .02110 Wall Construction struction$,andordc and that a
7.Is this a repair to an existing well; OYcs or I'2 u mo,of m nro.r'hoc been/ nAed l.,me ll mini..
If'hia 11 o repair.Jill out known null Ionrnucnan:n/bnnounn and nxplum[hr namr 01th,:
repair under-2I rvnaki enciion or on the Foci n/lh titan 7.i.Site diagram or additional well details:
You may use to back at'Las page to provide additional will site details or well
6.Number of peps constructed: Cont-nlcrion details, You h',av alpi coach additional pages if necessary
roe urulrrple inpcon a.nun-Aar„r::u(pph.10,av7J'w,m oh,none C!:s*rucaon.uws Chu sLx3,i7Tr AL tN$TL'CTIONS
Oslo/acin leriti,
9,Total well depth below land surface _96S-- ,(h.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple',elk lir,all deprhe,%'[L//,rent/emmple-3rry'2UIi'card dp1,7(1) COnc'.netion to Lila following
10-Static water level below top of casing: 50 al Division of Water Quality,Information Processing Unit.
If co/er Pe el0 ounce tong.uer'' 1617 Mall Service Centre,Raleigh,NC 2:699•i 617 .
II.Borehole diameter: 6 (In.) '-415. For Inleaiun Wells, In addition to sending the form 0 the address in 245
Rotary above. also 51411 eit a copy of this loins within 30 days of conmlcbol of well
12.Well construction method: M _ conscuaion mu Tim following.
ti.c uuges.'story.cable,direct path.etc,)
Division of Watt'Quality,Underground Injection Control Peuerenn
FOR WATER 5L:PPLI'WELLS ONLY: — —1 1636 Mall Service Center.Raleigh.NC 27699-1636
(gP )— Open Flow,_...•, 24c.For Water Snonls.L Injection Wells: In addition to sending the form to
I3a.Yield m S Method oftest.._— — the uddeoss(e5) above, also submit one copy of Nis form within 30 days of
13b.Disinfection type' Chic:Tabs Amount. 1 112_Lb5 _ completion of well constructioi to the county health department of the county
u'h:�+e construcmd.
F,,',Ow'I Naafi Canohmt Depornnea of Env:ronrntoa and Na:nal Resource;-Division er'vain•rmre,• Revised)an.291?