HomeMy WebLinkAboutWELL-02-2022-165101.TIF WELL CONS `RUCTION RECORD GW
For Internal Use Only:
L Well Cantmeta'r Information:
Kyle C. Shaw. •
WellConuactor7vamt 14.WATER ZONES
4521- FRO1Nf TO { DESCRt?TION
A _�. 5 sJ
5'
INC:Well Contractor Certification Numberft.
LLC IS..OUTER TCASE IG(for O mullitsied wells)OR LINTER Gf ap }cable)
Advanced Well Drilling
Como!:Name I.
DIAlrFfEtt fHIC7.TiF£4 i1L171 tAI
6 Heavy PVC
2.Well Construction Pe / f� L. .--'''7
{7( L ... % f- lb.IMER CASING OR MEDIC-(geothermal glared-Iaa
unit#:t.•14,"V ,v FROM TO DIAnfrrER n)
List all applicable well earstntction permiis(Le Ci7C.CoVariance.
TRIMNESS htxTElt[Ar.
County.Snare Nm la,tcz Ex)
0- ft. i n.
3.Well Use(check well use): 2
Water Supply Well: t7_SCREEN t` tr<
t7. icultufttl dlltuaicipallPublic _FROM TO ,»u 1t SLOT SUM YEOCrWEs3 IrAZERA1
it. tt ire.00p(ternial(Ii ting/Cooling SuP P �Residential Vvater$upp;y(sir.gI } R ft
DIndustrial/Cbntmelcialin
sidceiial Water Supply(shared) ,_
OR
°irrigation. ^1S.CROtJT
❑Wells>100.000 GPD l FROM TO NLATER/AL EMPLACEMENT i t OD S ANaLTT
Non-Water Supply Well: - _
t�t�2nnit�;,, R Bentonite Poured
injection Well:
ORecovzr3 ft. it
-
❑Aquifer Recharge ❑Grouadnater Rtmediation ft. It1 _
IJAquifar Storage and Recovery I9.SA`NDIGItty PACb(if npprienhle
Q Salinity Barrier -FROM To
°Aquifer Test nrATru r�ftAeeatfiiVVTarsnlon
OStornmater Drainage it rt.
OE tperimental Technology ❑Subsidence Control iL
❑Occtlierrnal(Closed Loop) OTracer ,
Q.DR17.L.D GI,OG("attach additional sheet,Ifnerrisnrv)
Oc� I(IieatinelCoolin�
-- —�— .Return) ppiftzr(z pl¢in under=21 Remarks)
� FROM R TO I DESCRIPTION(calor,innLtess so reetatfge.grata dim ex.)
4.Date 11r J 9 ^, a L/_S R' ,r� �- /l 4s�ells}Conrptetetl: LT >> Well II? _ '< R C R /J f -
aa.Well Location: IOW'�L ���
!f f` c' v— ft t
.� � J v•: !/J-�iJ n r�,1 f u/ r�
ar71� c�P1C ,�re 5 et_ R /
`*Faeilitylo �tarne - fi I
Facility ID=Cif appliable)
�,L
l U j!•1, ,1. l�r-- n ,
Physical tlddress,city;und zip it 1
ft.
r
L'7-r • .I_REMARKS
County
Parcel IdvrtiuratienNo.TIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
;ifwel(Ee;d,ens lat/loas is sufficient;
22.Certification:
z,,,l'ip:hij.j___
6.Is(are)the well(s): !.'Pe.rmanent or °Temporar Ssgn of Ccttilied Well Contractor r _
Date
7.Is this a repair to an e3fsti v 13rsigning tbi-form I hereby cern:6.0hcr the u-Pll(s)was(were)conw'uracd in accordant svid)
rug well- ❑YES or Mi o /S.d\C4C 02C.0100 or 15.1 AVAC O2C.CP00 P721l Conttrnetion Standards and that n coin'
If(kris a repair•fill oat ttr0wn Weil co,um trap irtfarmation and explain the nature gfthe of tar retard has been prmrded to the usall oxner.
repay n,der 421 rarnatta section or on the back vfthis for,r
8.For GeoprobdDPT or Closed-Loop Geotbernall Wells hevin the same 3'Ste diagram or additional well details:
You may vse the bark of this page to provide additional well conshvction info
drills ucnon only 1 GW 1 is tended. indicate TOTAL NUMBER of Weis (add'sec Over'in Remarks Box).You stay also attach additional pages if necessary.
drilled:
9.Total well depth below Iand surface: '-1 SUBMITTAL L1'STRUCTI0IS
For multiple weEs fin all depths ifafl"ercnr(eta J�. (fL)
ja'o-�d_'JO'wad3gIG0? Submit this GW-1nithin30dnvsofwellco completion mP per the fallossin�
I0.Static stater level below of casing �1 V 24a. For All Wells: On end form to Division of Water Resources (DAR),
I10.Static
isa r level
use top (ft-) Information Processing Unit,1617_l•I5 Raleig
h,gh,NC 27699-1617
11.Borehole diameter: (l 24b. For Infection Wells: Copy to DWI;. Underground Injection Control (TUC)
12.Well cortstrttctfon n P o ram, 1636 MSC,Rnlelah,NC 276 99-2 63 6
method 1 r— rC-o i`,-•t
(ie auger tatazy,cable direst push.ere.) / 24c.For Water Supply and Open-Loop Geothermal Return Wells:CoP! Co the
co:my environmental health d epartment of the county where installed
FOR WATER SUPPLY WELLS ORZ,F:
. 2-td.For Water Wells rode ' Copy R,
13a.Yield ^^ over 100�000 GPD: to DWR,
�Wn) �"' Method oftest Air f Pemit Program, l6iI Raleigh NC27 99-1611
131, Disinfection tie: NTH 1
Amount: 1%
rt a IW4
�f7 all Caralna t?er mrmr r nfFr,n. _ .