HomeMy WebLinkAboutWELL-05-2016-072752.TIF y
raRom : MORETZ WELL & PUMP FAX NO. : 7044621322 Jun. 29 2016 04:32PM P1
■ WELL CONSTRUCTION RECORD For Internal the ONLY:
nil form can be used for singie or multiple wells
I.Well Contractor Information:
;'IC%ATEITIONS I cRSeiSek se;:r.v.V,, as�,n :w;-Af0 , _
Ashley T. Moretz FROM TO DESCRIPTION
Well Contractor Name //oft- 300 et .2-sit"
2586-A 31O EL 32O f` y v/ s-
NCWell Contractor CeniE lion Number 15pOL a'CASING(fnntiiultd'aa ellITOR.LINER(ire lieublel'C:
FROM TO DIAMETER TRZCKNERS MATERIAL
Moretz Well Drilling Q n' /05-ft
€x. in s'/4i ,dL
416:INNE CASINCOR1TR NG(gea eimlifilcee141ane)-t'a31:3: f x .0
_Z;!':.
Cnmry nY Name
_ FRO M TO DIAMETER
TRICCNrSS MATERIAL
2.Well Construction Permit*I: 0S 2OI G �7� S f
Lin all applicable well permits fi r.Counrv.4orc.varinmr /n/scrton,arc) 1n
3.Well Use(check well use): §-173SCREE67. 1:......r 12:t':.'.: I n-': ::': -- r :'':'
FROM TO DIAMETER SIOTSIZE TIIICTCNEyc MATERIAL
Water Supply Well: A. ft
in.
O Agricultural OMunicipal/Puhlic _ -
R,
in.
°Geotherm l(Heating/Cooling Supply) mk:tendril Water Supply(single) _ _
tilB:iGROklarlcAla .kr.etrWlkny(. ytig-:in.. 4f . ?7:2'27 t 'kroltlk
Glndustnal/Commercial flResidrntiel Water Supply(shared) -mom TO m2krtaNL EMPtsrEMENTmenlon a AMOUNT
Non-RaaOn 0 R 20 O- 62- iL`r 00t.r d
Non-Water Supply Well: V R, /
°Monitoring °Recovery
-Injection Well: ft. f
❑Aquifer Recharge °Groundwater Remediatiun '•t9^SANDCRA WTACFCEFdaPlibble)'?:1P.h;A r t` '., [:3 W.:+�..3,q:,
FROM •TO MATERIAL I EMimnamENT Munson
°Aquifer Storage and Recovery °Salinity Ranier q_
°Aquifer Test °Slomtwater Drainage ft
Gpxperimental Technology °Subsidence Control •,2arORw rlNGi: I -
1.OGlfifimib'AddFdc aletiei si4Aiasmfr.Aia:free :ntis'2sn,;.::a.;:::
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,Amino',mninzea MM.grab"in.nrte.)
OCsmdtemtal(ideating/Cooling R Cmrn) °Other(explain under 1121 Remarks) 0 R /00 D- C.h1/4‘ gA/�yr 5Ptu i
4.Date Wells)Completed:6'e.2o/6 Well IDS /0 Of t y0 --__ d4-{/rC_
ft. fL
fen fL
/Well Location; C ft.
Dt_v&k Filr5 ft_ a
FaeilliiJy/Owner Name /� / Facility We(if applicable) ft R -
7 °I9/.S A/ltifr.)eN nvt ,4c / ir.de r a a
i
Physical Address,Cry.and Zip .:tflREPLARTESr::=X'r. 'le„.4; ` 11 i:..ld•°.: wisp _ ,';;.03`r. 1
{at-FAA-10o_ 347‘033369,45—
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: n Certification:
(if well field,ooe tat/lona is Pis ficien0
3 5a 556 V/9 N s/r /°S-5-7a W ,�v Eel!.7/A
� Signature oft ed ell Co Date
6.!s(are)the well(s): li7permancnt or °Temporary $y rlgning this farm,1 hereby eerrify than the well4)was(awe)caurrucled In accordance
/ with HA NCAC 02(7.0100 nr 15A NC:Arf 0x:.0200 Well Comtrucilon Standards and shot a
7.IA this a repair to an existing well: MY ea or n copy of tALe record has been provided to the well owner.
if this is a repair.fill out known well construction information and explain the nature of rho
repot,under 111 remarks.sea0an ur on the bock of this 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 constrecled: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same coasmacerin,you can
suhmn one form SURMITTAI.INSTTICTIONS
9.Total well depth below land surface: YO.-Cr (f.) Zia. For All Well: Submit this 2rm within 30 days of completion of well
for mvhple was Ln all depth,lfdg•rent(example-3 00'and 2a@ Ifds') consuucuon to the following'
10.Static water level below top of casing:_ Sb (ft.) Division of Water Resources,Information Processing Unit,
If water level is above aping.use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
I.Borehole dlameten 6 (in.) 24b. Fur Fnjection Wells ONLY: In addition to sending the form to the address in
D 242 above, also submit a copy of this form within 30 days of completion of well
12.Well conttrnetioa method: iq 1 f 1 r !`8//1.r;/ construction to the following:
(i.e.auger,rotary.cable.direct push.etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1636 Mad Service Center,Raleigh,NC 27699.1636
132.Yield(gum) 6_.__�. Method of test: A f I f I /f Nc.For Water Supply it Injection Wells:
Mao subenn one copy of thia form within 30 days of completion of
136.Disinfection type: !I' Amount: /0 0 Z well construction to the county health department of the county where
Q
COIISIrUCtcd,
Vann OW-I North Carolina Department of Environment and Natural Rcsoureta-Division of Water Resources Revised August 2013