HomeMy WebLinkAboutWELL-10-2015-065360.TIF 04/26/2016 07:43 7048924705 EKWELLDR ILL ING PAGE 01
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WELL CONSTRUCTION RECORD For Internal We ONLY
This Form can he used for noble or multiple well,
I.Well Contractor Information; _ -rr- l„( , a yl '.3,:l;lll l alIhi iiil,i-Robert E Teague FROM TO DESCRIPTION
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Well Connector Name
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2557-A -sI aD to ,e.:ii31f�':*l r a° ; lulls,' :?' 7.■
NC Well Contractor Certification Number FROM TO DIAMETER 7WCTLNEFF MATERIAL
B & K Well Drilling Inc. D ft. 'O cc. 6 1/8 I"' SDR-21 PVC
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Company Name DIAMETER , ..
3 J ROM TO THICKNESS MATER AI
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2.Well Construction PcrmltN --
Lin all applicable hell cnnnrvmlen pc it r e.Couno Hate. Varian:sr.err) R h
3.Well Use(check well use): :;F7„&"gflA it ii'+ t uh "
FROM TO DIAMe1YR 6tgT SIZE THICKNESS ,�MATERIAL
Waler Supply Well: ft. n. In
❑Agricultural ❑Municipal/Public
R R-
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°Gcothermal(Hcatino,/Cooling Supply) OResidential Water Supply(single) li„ „rnYi;n-` ;;;i): YI !i''r'
[Industrial/Commercial ❑Residential Water Supply(shared) •Pit o'N TO I MATERIAL EMPLACEM¢NT METHOD&AMOVN'T
°Irrigalion 0 it 20 h- Hole Plug Pour/Hydrate
Non-Water Supply Well: R. R.
OMOnitm'ing ❑Recovery — —
R. rte
Injection Well:
DAquifer Recharge ❑Groundwater Remediation I_l:lM'- ZHA.ie” "
FROM EMPIACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R.
O Aquifer Test OSrormwater Drainage n
❑Ex crimental Technology ❑Subsidence Control r. ! I :
°Geothermal(Closed Loop) ❑Tracer vROM T scRIPTTL2N(tale,ha n, poionmee wFe,rra•t nu,rtc.l
❑Geothermal(Heating/Cooling Return) °Other(explain under 0'21 Remarks) a a .O ft 1 r o �
50 n. 09, tr rJ n04--
d,Date Weill')Completeclit,Y )h Weil IDH n• • n' L. Y / (v
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Su.Well Location: y R. /J ^ (%
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r aity/C wner Name Facility IDd(ifepphwble) n ft.
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9 PIS h-16 1,a efJ n a'rt ft '
Physi I Address.C'y)'.and Zip 21:n,ny+ r ,;; .1vpll l r
CCOa>w L77OD6 C:24 57,2W
County Parcel Identification No.(PIN)
5l,.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
2t Ce shoo: J
fifwdl 6elu,me iatlong is su)licient)N W Z�r .a.a! -2.9‘.5 -lie'
Signature of Ccnilied Well Contractor Date
6.Is(are)the well(s): 171Permanenl or OTemporar[i Hy signing that/i+rm. I hereby tem))that the wean')awls(were)consrrvord,n ae<uLLsnce
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with 15A NC'AC'ox:.Ill00 or 1SA Ye.A( OTC.1200 Well Converse/ion Srordrwb and prat u
7.Is this a repair to on existing well: CYes or No copy ofroo record has been provided to the wolf owner
litho is a repair.Jill out known well con,lrvnion Informmlon and et Own the norme of she
reluir under.I remark,section or on Oh'hack fhb form. 23.Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Far mvlople ijenion or non-waur.wpply wells ON[.V with mu same conrrran6M.you con
SUBMITTAL INSTUCTf0N5
ruhma one Gtrn
9.Total well depth below land surface: SAS (Cc) 232. For All Wells: Submit this form within 30 days Of completion of well
F„nn,ublple wells h.,all depth,r/'dt/Jbent(crumple-3r S200'sod 2(]100'1 construction to the following:
l0.Static water level below fop of casing; SO (R) Division of Water Quality,Information Processing Unit,
If water level rr oho,:cr n,nx.or 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.)
6 24b. For Injection Wells: In addition to sending the form to the address in 24a
Rota ry above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
6.e.auger.rotary.cable.direct pu.h etc.)
Division of Water Quality.Underground Injection Control Program,
wog WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) a• _ Method of teat: Open Flow 2ac.For Water SIMIAN&ISOM.Wells: In addition to sending the form to
the eddiess(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Depanment ofF vironmeol and Natural Resources—DinhiOn of Want Qualify Revised Jan.2013