HomeMy WebLinkAboutWELL-03-2022-167499.TIF Print Form
WE1.1 CO tNSTk ( tlU\ RF.( i)RI) j(;11-1I I For Inernal Use Only. —
1.Well Contractor IlllotnLtl)nrt: I -- I
Robert Teague Ik 4,R wATZOlY '
-_._ _. I FRO51 [TO DESCR;PT1Os
V.r:l rentriclor same (t. ft.
B&K Well DnlGng Inc I h. it.
NC Well Connector Ceruication NumM 115.OUTER CASING(fa-monrtased wtl k)OR LINER of apylicabk)
2857-A Rost TTOOf. DL{SISTER I TRICh1•E.55 1 MATERIAL
0 ft. I16Sh. I g.r$ tn. I SDR•21 I PVC
Coalpaa;Marx I ] //' 116.INNER CASING OR T(([:BLNG(geothermal dosed-loop)
f 1 L /�[A' 1 fROst TO DIAMETER THICIOLSS I �/1T ERI.L
2.Well Construction Permit P: V 4r «t]!! -7 I ft. I h. In.
r.u:.d.'aFO5csb4.e'Icmis•^+iscn;,,,.:s;•: !7C'(•o:r��m.host ' •,v,,,e etI
"__ -I it. in.
3.%Nell Cse(check well uscl: fl
r Water Supply W 17.SCREE
ell: Heusi ! to 1 omt-rtR I SLUT e12F T THICK rISi j^NaTERraL
Agncuhuta) OA11.ntctpaLPublic •
_ it. I ft. I 1°7
Geothermal(Hcatin Cooking Supply) Residential Water Supply(single) rt. I rt. I in. I 1
lndustriaiCommercial 2esidential Water Supply(shared) is.GRODT
Irigat:J.1 FAOst TO 1 sLSTEBLIL 1 EItPL%CENF?T 12TAOD a 5NOn?T_,1
Nuts-Water Supply W ell: ft. ft. 1
)tor.t:oncc °Recovery' -- I It. ft. _,
T — TI -- .__---_-- ---
Injection Well. It. ; tt•
Aquifer Recharge Groundwater Remednyton ' -
,9.SAADiC,IG1S'EL PACK(ffa IkabkS yPLACE�tE�TSIETHOD
�Agmfcr Test �Stormwatcri Drainage '
Aquifer Storage and Reco-.er (jSalinityBarrier . FRO)t _..I_TO )LSTERIAL E.
ft. • ft. I '
-• - '
Eikpenmealal Techrolog; 0St.bsldeoce Control ___
Geothermal(Closed LOOP) ❑T�Ler IA DRII.LLVGLOG(■uachadd'Nios.l+>ItIco!, afu")
fK0�1 I TO DE$CN VTION rcobr. .don.Mllnck eye gvt.an.cm)
�}t,00tbefnaal(HeatineiCoolinc Return) 0f)ther(esplain under 421 Remarks) F Q ft Ii as�fftt. I0 t [.-A. d/ Lj
4,Date W ell(s)Completed- it, W ell 1D- 1 I�S It. I S !1/a.YL RI(., YI 1-AC'
ia.W el(Location: OSfr. I rt.j��Y� sc
�J651. 4 It. (i�� Gc -
Fyd,,ry OMB:tiaas, ;ac;Lty 1D4 Ii(applicabk) It. ---
qS r LA 3 -Ns v 1 ra h O fr fr. fr.
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Physical Address.Cry,and Zip �.�-t � - h �
1 21.116isIdLAKS
cs.L
County Parcel ldantificaionNo i?TN l --.—....- — I
I
ib,Latitude and longitude in degrees minutes/wands or decimal degrees: ----
iifwc':Ifiedoric4L'anc;aauAcK*i) ...Corn()
r--( StaT'rrom o ts ti f Can IN:I Hncr D.`
6.blare)the wcA U(s)ElPermanent nr Tempnrary
,,,...{{{ gs usn:na dl:.c lama i be/tin cars()that the tam r. mere/catvnued us ac'tortias..-
7,is this a repair to an esisting w oil: D Y es or d ,o +.uh OA A'C.lC 02C.01J0 or!IA.NC'AC JK.U201)ad!Cunaa that.,
w,non Standard,and
.;iota et s t[yaar.l:f one inv.',wrli tnro:n,diol;arnnnaune U. r.piatn tee rtattwt'al
royp of tilt teen!a hat been prre:dcd to the sieil otiuer.
ride under RI rrMat ken mctwe(it tin Si,'i hm k../•F,, .m 23.Site diagram or additional well details:
6.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the same You Ina.use he buds of this pa c to pro.ide additional wed slat details or well
construction,only i GW-I is needed Indicate TOTAL`(G�1BER-ot dray
cOrstnicttor decal's You may also attach additional pages if necessary.
daaed
__ SL"ITT At t'SSTKLQtO''S
9.Total will depth low land surface: ei c eft•) 14a. For All Wedz: Submit this 'Drm Withni 30 da}s of cumplet:ott of we.l
^
pn,+,mil:m.r,t r.'it:at:�:i,ur,rk•/c:/(nrm':a,:'r-::•J4i.JO'a•C.?;..3 Inn', cOrstrtcttin to the t'llowinz.
40 10.State (tit Dis isiun of Nater Resources,information Processing Init.'ate/let el below top of casing:
;r t.t :. ,�,r•::rs 1617 Mail Service Center,Raleigh,NC 27699-1617
• 11.Borehole diameter: 6 1/8 (in.) 11b.Fpr Iniection W ells: In aodsuon to sii.Jing IN:form to the aedress in'-la
Air Rotary ubusc.aisJ s_bmit one cup) if:his form within 30 days of completion of well
12.W ell construction atetbud;� coastnlcuort to the ioUowmg
i i c a.:aus tour, ,a:.e..L•e.A p,.ih.e
Disision of Water Resources.Cuderground injection Control Program,
t FOR WATER SUPPLY WELLS O"l.Y: 1636?sail Service Center,Raleigh,NC 27699-1636
131.Yield(gpm) S d 'Method of test:Air blow 24c.For Water Stipp!).& Injection Wells: in aaathoa to sending the font to
the acdessf•es) above. aso submit oar cops of that form Within 30 days of
}13b.Disinfection eye:
Chlor Taos Anruunr I'-2`a. completion of wen con+iructlon to the county health department of the county
'ai}K,ic cun►tttxtcd
Fe-'n Ow-,, \.>.--:a"",'Cc:aes*ietn atEnnronmenri shahs..Dsuio+i o`.w sic ot..r:n
Rnned_22-20t•