HomeMy WebLinkAboutWELL-08-2023-201453.TIF NW
11 Farm
NIMIN'E .1. CO\�7K( cl lO\ RECORD ( W-11 I''t leer=,ilII' c tlny 1.Well Contractor Information:
Robert Teague --
Weu i ar:r.cmc'saarc L 4l,RATER ZUfyCS --- --
2857-A ;1No i In urccRlr1lo ----
a/.3ft a.R, /s G
Vl w:ll i x•kgpr Ccrr,U:atson��'r+Cr n. R �.`.. i. -i-
B&K Kell Dulling Inc I3.OVTER CASING int maltl.cued wells)UR L1,9%if/petiabke
0� i rU 6Utrirk TIIICA�F,, NarfAUL� :
Coaoir%Vast Q
t IL rt.
6I+8 in. cDR•71 WC
«Well Construction Permit' - / s 3 I A �
y 16.INNER CA. G R TUBING(feathertnd e )
to:a::Azraai!.te.44"Mttre,• f71UN TO DlavtfrFli THICK>:ESS i MAMMAL
t,c+.J.r w.rs r+r (.< <+m-) Garr l.a.ranre ere, If. I R, in.
3.Nell Lit lchcel.well use):
it. R. I la, iL
Water Supply Well: i
17.4CREE:K
1gsi.ulr.al ONtuniclpal Public F"®� TO DIAV&TER SLOTSI/.t T1006,4 S5 aIATER1.aL
Geothermal)Heating Cooling Supply) Residential Water Su ft in. 1
4-tlndushviCwnmerrW Supply(single) 1
QResidenUel 1%aler Sup R' R. In r
lm uon Supply(shared)
ta.FG�Rn�L7.��,,
Non -ator SuPP1� 14c11: ""` ■��W �:titciFi�illottocimaut Ctrrrmaw
italll
A!�r.,toting n. ft.
Injection filet(; Recovery ®� '
Aquifer RA harp;
❑Gtoundwatct Rcm.dlation MILS R•
0.•yquifer Storm and Recovery 19.SAND.t;RAt gL PACK Irca,.
C]Aquifer Test ❑Salinity Barrier t o cable
II ataTERIaC ENPLACEyIENfNETHOD
❑Stonnwater Drainage
IIIIIIMI
ID ExperimentalTechnology 0Subsidence Control 1111111111111
Geothermal(Closed Loop) QTracer
Ciec+thenrtal(Hearin lCoolin 20.DRILLLNG LOG attach additional sheen N arusx Return) Other(ex lain under e21 Remarks) P.
o.vt nr:VCRIPTL7.N[tote heron...,wurrwa et... ma taw etc
4.Date Wells)Completed: '3 ��
Well lDp A.4 J •
Si.W'dl Location:
� . C, . a
Fa:ihq-'CAne-%ante I -
Facihty IDa ti applxah.ci R. R.
Physical Addrea Vol s City. ft R
y,and Z
n. ft.
C-'G\ (r.i1.e.-. 21.REMARKS
Count
ii
Parcel Identification No.(PIN}
5b.Latitude and longitude in degreesiminutesiseconds or decimal degrees. !
Of well field.one u:'long u sufficient)
22.Certifigdona----,
W Contractor 7
Si
6 Is(are)the TFell(s)@Permanetit or Temporary 5 - 3 G` 1 3
y`r+aturc of Cmiticd Via
7,is thIs a repair to an existing well: BY ti ring thrt jo.rn.I hereht ce,t r A u the tte11 r
E Yea or No <irh.15 V r V f!nut Near)constructed tend r (toad a t a
If his is a repmrr fill oat bran,,,ell mnrtrucuun rnjor Aunn d•CMC 4.0 O here pnn•+ileil en the well unorr
Oil the bock of Mu fanrr
8.For GeoprobtiDPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction.only I GW I is needed. Indicate TOTAL NUMBER of wells
dolled: construction details. You may also attach additional pages if necessary.
9.Total Well deist SUBMITTAL Ikc'rRL'CTIQ\s
p ow land surface (ft.)
For rrwapir wilt hi:all depths i,'d;Rerenr roar pie•1 ;n0 and)r^ylrlo'I 24a• All 11' 11: Submit this form within 30 days of completion of well 1
10.Static water level below top(leasing:40 construction to the following
l S ticel u le teens we - (ft.) Division of Water Resources,Information Processing Unit,
1 t.Borehole diameter: 6 �/8 1617 Mail Senice Center,Raleigh,NC 27649.1617
(in.) 24b.For Iniec_ Nun 1>ells: In addition to sending the form to the address in 24a
It Weil construction method Air Rotary above,also submit one copy of this form within 30 days of completion of well
(Le auger,lots,.,e4 1c.three:push etc I construction to the following:
Division of Water Resources.Underground Injection Control Program.
1636 Alai!Senice Center,Raleigh,NC 27699-1636
FOR WATER SL'PPL1'WELLS ONLY:
13a.Yield(gpm) 1 5— ylrthod of test: Air Flow 24
c. Su
o WainWainooh & Inieetio 14ells: In addition to sending
13b Disinfection nix: Chip-Tg s Amount.: the addreastest above. also submit one copyrm 30 form of
completion of well construction to the county healthsdepartment ofn
the o
where conxWc:ed county
Fain CU'•I
North Carolina Department of Ens romnental Qub:y.Drv+san of Water Resources
Revised 2.22.2016