HomeMy WebLinkAboutWELL-03-2022-168580.TIF • r r.PrIrltFarm.r
WEI,l,CO\ti'l-Rl('T1O\ RF:('O1U) SGW-11 Fnt internal Use Only
i n ell Contractor Information:
Robert Teague FRId;FI'ATFR7.ONF�
. nvI i^in OE.OMTIM
Wri'Cortrartoi Name
S ft, /ti+ h. G rh
B & K 1h'ell Drilling inc 7o ft. 7 5 0. I - t'�
,lilt
1 5.OUTER CASING(for multi-cared wells OR LINER if
C wen Cen*ac irr Cend;cu w,Nu nbrt MA T ERIaL
i-FAo>I I to DIAb1ETF.R_ ifflCA_E55
2857-A 0 II. i ft. 5'A in. 5014.21 PVC
ConFany`+nc f/�X ( 16.INNERCASINGORTUBII'Gj nalclose --too.
' ll J -) '�` ) FROsi 1 TO ' DIAMETER TNI
2.Well Construction Permit 0: fI. J I '."'
ful n9 up0h[ublc•e!!.aurnut;on prr+rtar is e. LA'.Loann,Sure.'ranmrc[.el(I � f t. I I L-1Q_.�_
rt. 1 rt. in. I
3.Well Use(check Hell use):
17.SCREEN , 14TEUL
Waler Supply'A ill; 17
Ot4tl E1 C tiWT RILEI TNI'K,y LSS ,�-R----
0Agncultural 0MuntcipeUPublIL -
DOcothcnnal(Reating,Cooling Supply) ,Ratdcntial 1Vatcr Supply(single)
DInduslraUComnierchl ❑kcsldenual Water Supply(shared) 3.GROTJT rcrpUEK CyNTstETvuOitiMUt`rT
I�
FROM la 'L1TF' •
Irc;glfiUn h. rt.
Nun-Water Supply Well:
Cl'ttmon 0Rccuvm
Injection Well: IMIIIINNIIIIIIIIIIIIIIP
ID AquiferRecharge OC,roundwafer Remcdiyson 19.SAND/GRAVEL PACK(•if a9•ticablt
0 Aquifer Storage and Recovery SalinHumity Barrier F i To
I MATERIAL E.vtPLACE.�fE�T METHOD
[]Aquifer Test 0Stormwatct Drainage
ft. ft.
[3B Experimental Technology Subsidence Control n. ft. -�
Geothermal(Closed Loop) Tracer 2A.DR.1.ING LOG attach aeSCtleTiO o i<' •- la an.etei
t 1'+� a ttion isle no n soli' .•
Geothermal(Heating Coolinc Return) Other(explain under r21 Remarks) III - •
- 11
rr //`� ft. It ft. • r S
a,Date Hellls)Complstedi..• L 1-c7.Well IDtr V
Sa.Well Location: `5Tc•t' e
1 ft. ft.
`4\vH2 ?n1►•k r r ‘.40(hCS
Facdlty'Owser Name Facility Ma tit applicable) fr.
CILA )L. 1( I YIzYh1)r. .).1P1.-r-itiS 4r.Dr:-) ft. � ft.
Physical Addre;s.City.and Zap
Gi,�` owA7c.`
County P:rceI tdentit rtipa No IPINi
Sb.Latitude and longitude in degreeslminulesisecunds or decimal degrees:
(tfwell field one 1sc'tong*sufficient) 22.W Certificatto
N � 4 - `/"�
, .t�
;oam.•,af Cenified We�k{r ntrxtnr o
6.b(arc)the well(s) Permanent or [�Teinpnrary !were) onstructed in
51 signing Ws form,I het !ry crrlir5.that the nnfl/.tlw>a f Construction Standards and!ltaalca
soh 1 SA CAC 02C 0!')ar lie cC4C 02C.0200
7.Is this a repair to an existing well: Ql'es or N" copy of lkia rr[n,d bat heen prnvrdcd in the well a,an[r.
If Au is a repair.fill ma know wtli rnnstnrcr;an a linnnarron end explain rke nauuc•of Of
rr ale under al remarks arcf/on or tin:kr bar k of Air farm. r 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or sell
6.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha+,in;the same construction details. You may also attach additional pages if necessary
constriction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 `/g� SUBMITTAL eel : ubaiit S
9.Total well depth below land surface: L (R•) 21a. For All Weds: Submit :his form within 30 der. of completion of well
For multiple rrll,hi,all drpdn ifd:ffrrent rrrarnp1e 1 u_OJ and @/NY? cons rucOon to the following..
10.Static water leveel blow top of casing:
40 fft.) Division of Neater Resources.Information Processing Unit.
lfnotn•lr.rl h ahem,caning,me"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
' 11.Borehole diameter:
6 1/8 (in.) 21b.For Injection Wells: In addition to sending the form to the address in '_4a
Air Rotary above.also submit one copy of this form within 30 days of completion of we
ll
12.Hell construction method: constllcuon to the f0110.00g:
I i.e.auger.toury.cabie.direct push.eic.1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,\C 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c. For Water Supply&injection Wells: In addition to.vending the fate to
the addresses) above, also submit one copy of this form within 30 days of
Chlcr Tabs t Ira gas completion of well construction to the countyhealth depariumt of the county
13b.Disinfection type: Amount:
who u Lonstrlv;tCd.
Form C.V.'-1
North Cuolrna Department of Ens,rcnmenml Quality•Ottlatori of Neater Rerm:rces Re ised 2.22-2016