HomeMy WebLinkAboutWELL-05-2021-151105 .rtafaY 1...1•AI,1,0.Amu)...t AL,..a 1 asw s.v.sr s"..,r• ., . -. .........-. _.. .. ,
1.WO Contactor laforwaationt l
Robert Teague L.,WATER 24:;i1
I F11o�i To Dt�CRWTrod
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'tYtllContltetarNanlc � n ft. J 7'2) tl. �t L�f��_
B&K Well Drilling Inc ,�f t ft. ft.
NC Well Covesetor Cs:reneuL a Nvmbei I S.OI)TE CASING tfor iasllkeared aelN)OR L tilf ilt aetillnkkt
2857-A . FRO*t LTO DtAMtT1R rmt t`'ppi MATERIAL ,
Cowpony Note "42,' i it ft. ram/ ft• b,� is p.xt PvC
116.INNER CASING OR T_UBINGigeolYerSM tiosikeop3
2,Well ConstJ tion Permit 0• , FROM To maw:rut THICKmeaS M 4Ttal*L
ft. ft. is.
Lae el ailhlta67e we1J oonttn aYion pmggirr n a.U1C' Colony State Ywnci ce.eh-I
3.Well fL ft. lc
Cee(check well use): ,
Water Supply Weil; 17.SCR tE14 FROM TO DI4MtTaa SLOTCIZL I rincio(Jy ' mvrtaivi
IDAgt'icultural DMuntcipaLPubtic ft. ft. is
i
EDGoothcnnal(Nesting/Cooling Supply) Ratdcntial Water Supply(single) R ft, in. i
0Industrial/Commercial [ Residential Water Supply lshared) �GROUT
n)maation FRum To minus I F DLACt W(TAICTHOD14 AMOI'vT
?quo-Water Suppi) Well: rt. It_
IDkionitonng ORccovcrs it. ft. l
Injection Well: rt. R. r
IDAquifer Recharge DC,roundwarer Rernedtyton 19.SAND1GRAvt?L PAC1Cflf applts7Qir1
Aquifer Storage and Recovery DSabrnry Harmer FROM .TO NL4TERIAL I ENrLActatt'T aNETHC O
3Aquifcc Tat DStormwatcr Drainage R' ft.
DFatpt:nmental Technology QSubsidence Control ft. ft.
DGoothomul(Closed Loop) ()Tracer 21.DRil,it4G LQ o(ataack aiNtha.i dreg(wo eemv/
O
rROM TO otSstiIT1oni atm t.wiVnc►raw,an it AN,eKl
Geothermal tHealing1Coolinp Return) [Other(explain under*21 Remarks) ftr_r
/ m. r4r-
j.I jfr
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4.Date Wells)Completed CT 9— 2 1 Well ID* +5C ft s-, n rt,I (te ,
• Ss.Well Location: �t 11(.. 1-4.)- 4 c3 ` r g//
I' L
2
T � o itV 1
it.
Fs:daryrOwner Name Facility lbs(if applicable l ft. ft.
Li 3 S vys.e f A(-) c ii)e its )41 ft. ft.
Physical Address.City.and Zip ft. ! ft. l
21.REMARKS '
County Parcel 11en.hfic.ttion No.INN) l
5b.Latitude and longitude in degteesiminutesisei:unda or decimal degrees.
(if welt field.one Iat ion`is sufficient) 22.Certif.)/ 61
7
N W /1,... „....,"
Slikeilua of cc ufi,.J cacti C,intev: Di&
6.Is(are)the well(s):3Permanent or f Tempnrary
By sigmas;hid form,1 he,c)n emu),that the*rib))wag N ue)coeseveted et eeeeeemkr
7,is this a repair to an existing well: ON es or �No ion 11A NCI(02C 01itO w 1JR.CAC OK.0200 Well Cuturrvsrfw Standard)vat/that.
litho as at epair.fr11 r's,i kaosi,well enn trsclion I�arniatran and plain the nature of int cope of thu rgrn,d hat hurt prowdcd to ihr cell Dower.
r r¢ti,u wndrr s,l rrw,writ telhua w un:he hot i u/rhia funs ' 23.Site diagram or additloatl well details:
b.For GeoprobeiDPT or Closed-Loop Geothermal Wells bavtn;the same You may use the back of this page to provide addidotul well site details ot well
coestnirnon,only W-1 is needed Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled; 3 8'tiLttTTAL INSTRUCTIONS
9.Total well depth below land surface: 0 S (ft.) 24a. For AU Wok: Submit this form within 30 days of completion of well
For•wlttpie.iellg hit ail depths r(dtfkrrnr,rsample-1 a_'!NJ'and 1100') cooSalletioe to the,following.
10.Static water level below top of casing: 40 Ift) Division of Water Resources,Information Processing Unit.
If.wtea if'..1.'dwty Caws,(tires - 1617 MaU Service Center,Raleigh,NC 27699-1617
• 11.Borehole diameter: 6 118 (In.) 24b.for Infection Wells: In addition to sending the tort to the address in:id
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well coDstruchoa method: construction to the fbUowiag
i ie.minm route•able.direct push.etc.t
Division of Water Resources,Underground Injection Control Program,
'FOR WATER SUPPLY WELLS ONLY: 1636 Dull Service Center,Raleigh NC 21499-1634
Ypm113a.Yield( ) Method of test:Au Flow 24e.For Water Supply&infection Welk: ht Kidlike to geode;the form to
the address(a) above, also submit one copy of this form %Tthia 30 days of
13b.Disinfection type: Chloe Tags Amount: l 112 tan complextoo of well cooi.ostimon to the county health dglsroneat of the county
when:constructed.
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