HomeMy WebLinkAboutWELL-01-2016-068206.TIF WELL CONSTRUCTION RECORD For biased use ONLY
This form eau be mad for single or multiple well
1.Well Contractor Information:
Ashley T. Moretz i4:WA ZW4 s<. -
- 1ntIM TO DESCRIPTION
Well Contractor Name $o 14 l TO Q it 76fin
2586-A 26510 7 `" spa 6jor1
NC Well ContactorCmiikenion Nmltba :1i,or7L*D: 0lfur inul&nxdva,)DR1:1NFR ilr )
More Well Drilling M1 R ,c DD M TER In '-in` MATERIAL•
o e6 1SORA/ I /tEi
Company Name /� ` It INNER CA�iC OH7Tlewcoreotb6nnta . . : .
2.Welt Construction Per�tatO/20/6-0622o6
FROM To ° $) Me7'ektAr. .
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fist oil applicable+r)7WtplIY<rlq permit}(-LC:fmWj.$m(C,Parlance.HG)
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3.Well Use(check wen use): _
-
Water Supply Wen: ° neon} TO - otame LTt Show SIZE YeuCmeE s MATERIAL
OAgdcultmal OM icipaVPublic
R. R la
OC:Wihemlal(Heating,/Cooling Supply) dcutiel Water Supply(single) R. is
OhdusniallCammtrcid QResidmrtial Water Supply(shared) -1g.('R9 +: ::. '.. :. .. .
PROM To MATERIAL EMPLA[MEATMcTROD&AMODKr
°Irrigation `C R o R ^ -_ .* a& d
Non water Supply Well: a+ �r+!`C!Y /p
OMonitodng _ DRecovcay h. ft.
Yn)ection Well: 1t. R
OAquifa-Recharge : OGrotmdwatcr Remedlation 19:SANb/Clavffi:p a. (flappllobd�):' ..
DAquifer Stomp and Recovery DSalini Barrier
mod �To ,� NA I. swewe6fNrxrmernpp
CAgtifer Test . DStmmwaterfhainage ' • s1—_-
R R r
Caper mmaal Technology . [Mulisi:knee Control
flGeahemW(closed Loop) OTrayar `20:DRILLTNQ I:M3{atueliDdnn,taafth I att hide r) e • .. -
FROM tq NRoby,bardaQm manna wpa,gaeo>$eat
CGeothermal(Beating/Cooling Return) DOther(explain imda#2I Remarks) 0 R / S. IL m 6. Ccyro 4 ie. S4
-�]] 7 / Ern.USSR ( nekt s, !( .ea
4.Dale Well(s)Completed:)I!'/tl Well IDH R R f!b
Sa Well Location; • R R
70141 find ley ft R
Facuiy/rnvn(ceNamo /j FaciilliitylDA(ifamine:O ) D. R
/n13 9 cn�Ater 161-■ely ALA m a
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21L liEMARnC5 ..... .. .
t 0\ • 32oayy3037
Ganry Pawl ldmitifisatiooNo.(PIN)
Sb.Latitude and Longitude in degree dmlautea/secondsor derma)degrees: 22.certification:
(if well field, ee iat/iooag is sufficient)
35/6511 f N W. 3ya 7 76 W � /1 3/77'6
� /
Si of Caulks!Wolf Contactor Dale
6.Is(are)the wails): b11ermanent or DTemporary
8s della,:thiticon.
020 7 hereby card)".ACC dm.070(0)eta(nee) non Srwid In and--
�� with ISA NCAC Dae.01 0 err/S ?CAC 01C.0100 well ea,ra.aavan Smndwdr and lira a
7.£s this a repair to an existing Ire& •Oyes' or do copy of this record has been provided to the Rdl owe,-
If this Is o repot',fill out known well constitution Informotton and explain the nature ofthe
repofr under all realm!.eea/un or on the be oft is farm. 23.Site diagram or additional well details:
You may a the buck of this page to provide additional well site details or well
8.Number ofwels constructed; - / consnucrimr details. Yw may also anach additional pages if necessary.
For mrddplc to/cotton or non-wirier ca pip wife ONLY with the same eaasnueffot.you can
etyma one Ann. 0 SUBMITTAL INS
AL rUCr1ONS
9.Total well depth below land surface: ' rL Bs (IL) 2da. For An Wells: Submit this form within 30 days of completion of well
For multiple wear atoll depth,(fdf)fcen(earnpfe-*ZOO"card 2 @)00) construction to the Mowing:
10.Static water level below top of casing: SO (ft.) Division of Water Quality,Information Processing Uait'
rywatcr level is above water use^+" 1617 Mall Smiles Crater,Raleigh,NC 27699-1617
11.Borehole diancter: 6 (in.) 24b.for frtietlion Wells: in addition to sending the form to the address iu 24a
Am 1 above, also submit a copy or this form within 30 days of completion of well
12.Well construction method: As 1 (4v construmoa to the following:
Cie auger,rotary.cable,dimes putt cm)
Division of Water Qoality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: yfl...y 1636 Mail Service Center,Raleigh,NC 27699-1636
13o.Yield(ypm) 6o Method of test: , l� 4"
a l 1 �.For Water Sanely&Infection Welly Jp addition to sending the lour m
'1 �j the address(m) above, also submit one copy of this form within 30 days of
13b Disinfection type. n ,v_ Amount r3 Q Z.- completion of well construction to the county health department of the county
where tan stnctcd.
Form 6W-I Noon Carolina Dcpvunen,of Envirenme rt and Natural Rcsemccs-Dlvisioo of Water Quality Pcviacd In 2013
Ed Wt)@T :80 9TOZ d0 'adU EE2TZ917GaL : ON Xbd dWld '8 11Bf1 Z1ddOW : WOeld
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