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HomeMy WebLinkAboutWELL-09-2015-064356.TIF WELL CONSTRUCTION RECORD For Internal Use ONLY: This firm can be tscd for single or maniple wells I.Well Contractor Intonation: Ashley T. Moretz :t4,wA7aRZpNetJ:=: . - FR• . m pgacwmgN • Well Contractor Name 40 R /00R • 2586-A fL ft. NC Well Conne orCa-nficotion Numym _IE.OUT'ER CASING genmaiLLuied meat)OR LINER pr liable) • Moretz Well Drilling atom Tb °"M " ! lUICININe MATERIAL 9 Q go ft bit in- [ware/ pc CenipanyName •1&INNER CASING C l t ) DIAMASm rMATaaAL Well Cnntraedon Permit 0:0 Q 42015 o6y35.6 n /list all applicable n l/cmumcxon per o m g.,Coen%sons Variance.err) R 3.Well Use(check well use): _12SLltE@l .i . Water Supply Well: PIWM TO mAMErmc surrtare THHICltrtesa MAIYRW. Agtitullluol Glls�tmicipeVPnbkc 2� R. ° OGcothermsl(Heating/Cooling Supply) •t esidentiel Water Supply(single) i9- OlndumiaiYCom[ncrcial ORcsidenBal Wabc Supply(��) -76:GROI7T ::-. .--. ..:....'...... PROM 'rD M TERUL 1941 PJMrM WORM ate AMOON7 Noo.Waoa R �0 �6A- i'�'C: Ci4o s, fo ttc{� Non-Water Sappily Well: 1 OMonitoripg °Recovery Infection Well: ft. R OAquiferRecharge OGroundhaler Remediaaon FROM TO MATnIUAi °Aquifer Storage and Recovery OSalinily Barrier eattPrrtCafbrrtm�rwop R °Aquifer Ttst OStmmwater Drainage ' ' © fir. ()Experimental Techndo&v , OSubddenee Control °Gtnthatdal(Closed[mop) OTracer tafeff, LOG(attach idd{donatabiete Onteasaip) FROM ti 'to R I u ON(m.r.n. . ww..a.tmeFraiaago OGeothcmtal(Heating/Cooling Return) °Other(explain under r721 Remarks) Q p a A/1 a Date WeRD)Campleteda d.i 77 Owens* on- /-2 r" Flo flock Se.Well Location: /Z S" 1 o S a 4t.e /Q�r� PPt� ft. R. Facility/ zir ai Facility iDe(if applicable) rt. R - c PUCShA LA/ 5AergUs fort R. tL Physical Ad&sSS.Clly,and Zip r IL rt. • . CA,S.w n/9oa2fl7ey7 County Final ldemifesi a No.(PIN) Sb.Latitude and Longitude in degrees/minutn/secoudsor decimal degrees: or a field.one In/long 4 suRrcint) 2L Gtrtifl®tlon: yea 35- 653 757 N 80. 966 530 W T 419°C '14 Immanent sigearenorc c w aann ell cntor • Dam 6.Is(are)the well(s): I mmanent or OTangtotaty By signing this form,f hereby eemry that the well(s)nut fnym)auntie rased in anwdmtta with ISA NCAC 02C 0100 or ISA NC0C 02C.0200 WdI Coartrretlon Manton mad that a 7.Is this a repair to an existing well: Oyes or HN°I copy edthis record has been provided to the ail nor. if thin is a repair,1111 out Grown nett cunsbyetlon inJNamrion and etiplaia the nature of the repair easieri71 rrmarkr titan or on the barn of&is frsm. 23.Slat diagram or at iltioaal well details: / Yon may ux the back of this page to provide additional well site details or well &Number dwells constructed: ( construction details. You may also attach additional pages if necessary. For reub,)tic:rjetxara or am-natosnegate walk 0 with the sante eaamvcaoa,ray con suborn infant n SUBMITTAL INSTUCTIONS 2 9.Total well depth below land surface: 0 5' (ft.) 24a.for An Welty &dente this form within 30 days of completion of well For owhip)e we/i lit all depth(/different(eemnple-S @2000 .01d2®/00) construction to the following: 10.Stack water level below top oftarliw J O (ft.) Division at Water Quality,Information Processing Unit,. y,.121<,level is abo.e anew;ere-...6 1617 Mail Serra Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6 „(in.) �( 7A0.For fnitxtlon Weal; is addition to sending the Item m Me address in 24a IL Well construction method: A t r R Q ek T' above, also submit a copy of this form within 30 days of completion of well construction to the following (i.e.auger.rotary,cable,diner muh.etc) • Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 130.Yield(fym) 7 Method of test•. t r /I T I 24 For Water Snooty&Inteeelon Wefts: In addition to sending the form to I'y�! - the admcs(ec) above, also submit one copy of this form within 30 days of 13b.Disinfection type: /"F f TT Atoning: 5 6 Z completion of well caastmcuon to the .aunty health department of the watery where constructed. From OW.I North Carona Deponent of Patviroan eat and Natural Resources-Division of Water Quality Revised Ian 100 4d WUZT :E0 STOZ 40 .add ZZ2T39440L : '0N Xtld dWfd '8 11EN Z1ddOW : WOdd