HomeMy WebLinkAboutWELL-11-2015-066941.TIF 04/11/2016 14:30 7048924705 EKWELLDRILLING PAGE 01
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I.Well Contractor Information: '•3'• eaJ.x:gliS
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Robert E Teague
Well Contrwtor Name
2857-A
NC Well Corgi-war Certification Number 'RO N ,Th. TO
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B & K Well Drilling Inc.
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Campa'Y - ft n
1 Well Likable enoR Permit n t� sinni.,. nam,.er _— f<, h br —
ht,e all oppGmryle Aril amry Glrn tyranny(t.e(owey "1
DIAMETER SLOT SIZE TH«C MATERIAL
3.Well Use(check well use- ,-. 1'0
Water Supply
N'e11: e, n• In.
DAgricultural 0 lunicipal/Public ft fl_ In. SIMI
�( __. -___ — ar11YiENEIIIANAi1W°,w�
Docothermai(,Heating/Cooling Supply) •Residental Water Supply(siuglej
1
❑Industrial/Commercial ^_Residential Water Supply(Shared) PROM Ifirall■ MATERIAL CNP4ACEMR.^«T MZTNODA AMOIa
nrrrigation • 0 D' 20 n Hole Plug Pour/Hydrate
Non-Water Supply WdLt n. ft.
^_Monitoring ❑Recovery R. n. —
Infeetion Welk t
❑Aquifer Recharge ❑Groundwamr Remedia[ton PPO� MATERIAL
EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barnet
DA4uiter Test ❑Stormwater Drainage Si ft.
°Experimental Technology °Subsidence Control
°Criothcrmal(Closed Loop) °Tracer etEn�e�73j�
❑Geothermal(Heating/Cooling Return) DOther(explain under 112( Remarks) wl�
5 n. 'r � a
4 � �
4.Date Wellts)Completed: N-2,-) ("Yell ID# 0 h.
5a.Well Location- ! �s ` �.
p A L- / )S A L-Q�
Facility/Owner Nemx Facility(De(if a ht blel n. ft.
9S S Yoj)ER cam,-�., 1 fl. n.
Physical Addreaa,Cir and Zip
a(n) f3L 09Dt.7 roil
County Parcel I der iitcaiion Nu.(PIN)
Orwell L Odd.o e Im l ng ghude In degreeslminutes/ae[ands or decimal degrees: 2s (.cr\I�cadon'
h.L titu one d Longitude nude Intl / ` �/p�io `�^
W q— u —/Ei
Siennture of Cenilied Well('nnoactm Date
6.Is(are)the well(s): DPermmient or OTemparary Hi.'raring dux form. I hereby eerilll tho the wellO)woo here/conrrrvned in accordance
with 154 ''(AC 0.21:.(5500 or/5A YCA('02i•.0200 Well Camwroan.1 iandonly and that o
7.Is this A repair to An existing well: es or °No inlay,fthis record hoe been provided m the well()WPC!.
///Thies is a repair,/ill soul knv,ro well como-uctivn inJdrmollon and explain the name:*of the
rupatr under U21 remark.Auction iron she hack iy inir form. 23.Site diagram or additional well details:
II You may use the back of this page to provide additional well site derails or well
9.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1•br nruhir✓e in/coos or vanity/0—q.pply,melts ONLY with ii.,,,tame mnwuetl.w,yore can
cuhndt one'Urn,. SUBMITTAL INSTUCTIONS
9.Tend well depth below land surface: G OS (D.) 2aa- For All Wells: Submit this form within 30 days of completion of well
For ntvinple n-e!G/in all depth..II different(erample-Iv?00•and lr @)00) construction to the following:
1e.Static water level below top of casing: 50 try.) Division of Water Quality,Information Processing Unit.
I/'water tercel n above eating.are ". 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter; 6 (in.) 24h. For Injection Welk: In addition to sending the form to the address in 24a
Rotary above. also submit a copy of this form within 30 days of completion of well
12.Well construction method; construction to the following.
pee auEer,rotary.cable,dared pu.h,etc.(
Division of Water Quailt>,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
' I Open Flow tae.Tor Water Snly&Inieennn Weill: In addition to sending the farm to
13x.Yield(gpml "� Method of test: p en ow nothe address(es) above also submit one copy of this form within 30 days Of
13h.Disinfection type: Ctllor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form OW-I North Caroline Drpartmmt efltnvlrnnmwl and Natural Rcaowcei-Division of Water Qualify Revised Jan.2013