1962 Milling Rd (4) WELL CONSTRUCTION RECORD For ralemalUse ONLY;
thin form can be used for aingic or train ple wcll•I
I.Well Contractor Information.
14.
Edwin Mullis F OMATFTO RZON$9 DLac:IIIPTION
Well Contrac-Nemo 120 ft 145 R' 120 2-,135 9 142-3
8518-A ft n.
NC Well Contrachrr Catilleat6n Numbet IS.OUTER CASING Ibrmaltl.eaacd wells OR LINER Ira lfeabla
FROM T j DIAMETER TUI•lcr1499 I MATIERIA1,
Gopher Utility Services Inc _ 0 189 n 61/8 i° 80R21 PVC
Company Namr. ta.INNER CASING OR TURINC enthcrmal elelvd-los
FaoM 7q n1AMRTER TNrc1WEs9 MATERIAL
2.Win Construction Permit ff.N/A •-' _ -.
Mtt o11 applleabhe tall permitt p,e,Corm$,,Sears,Variance.,!nI ere.) --.
ft.
3.Wel)Use(check well use): 17,6CRVEN
Water Supply Wen: PROM TO DI%Mcrna I SLOTSIZE T T1UCK1'M_ MATERIAL
(IAgrictlitural _MurticipaVPublic n• rL In. -- "
Geothermal RIeating/Cooling Supply) (Residential Water Supply(single) n'
Glndustrial/Commcnxiol (Residential Witter Supply(shared) 18,GROUT
FROM TO M.1Tt:RIAt EMPLACIDMINN'r eTHons.AMOU[Vr
Nott-Water Supply Well: 0 n' 54 n' Hole Plug Four
It. rt
„Monitoring Recovery
Injection Well: It. ft.
Aqulfat Rcebsrgc 10roundwater Remediation 19,BANDIGRAVELPACp ra lieable)
IrRUM TV
Aquifer Stcttttge and Recovery iSnlinity Hairier "� PLMATR( E PLAC£MrNT MLHUD -
—Aquifcr Test ,..StonrrwaterDritinagc
rL tt.
_Exporitnental Technology Gubslrlencc Control
ZD,DRILLING LOC; attneh additional shoeti IC necessa )
GeDthorinal(Closed Unp) Tracer FRp01 'm AESCRFTIUNp41RHnIuxe,NaJ
_Cootl,ct7ndl lialstin•Conlin ReturnIbther pt lain vn4or#21 Rcmnrka 0 rL 35 ff. Fled,b(bwtl dirt —�
4.state Well(s)Completed: 1/23114 well ID# 35 r<' 60 fr, 8andst6ne
60 rt• 71 "' SupBiiite
5a.WeLocation: 71 iso R' Mingled grenite;with quartz,Pink blue,
,lack Snow it R.
- grtlni(e
t'dcilWOwrlct Name Facility JD#(Irapplienble)
1962 Milling RdMoCkWille NC 27028 e. k----�—�
Physical Addtcss,City,and Zip 21.REMARKS
Davie
camty ramd rdenti6txttiod No.(rrN)
5b.lLgtitude and Longitude In degrees/mIzates/secasuls or decimal degrees: 22.Certification:
(itwell hold,one idUlung is nrTk lent)
85.5542 N 80,304 w
8rlmnturc orCortifled Wcli Contractor Dnra
6.is(nrv)the tvcll(s): Ir Pernuintnt or Temporary
By sfgning this farm,!herrhy car•rljy that the wclt(s)wet(wore)eoatvuetod In accordance
wish 13A NC'AC 020.0100 or 154 Nf:4C 02C.0200 Well Coattruction Standards and that a
7,1$this a repair to an existing}yell., [Yell or r No Copy of this record herr Koen pnwidad to tha sill owner,
jthtt ix a repair,fill our known wwV coottrucdon io(mmatian mid explain the nature.ofthe
repair under 1121 rrma4v srrllon or on die back of rhis form 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site devils or wcll
S.Number ofwrils congtructed: 1 construction dctaiis. You tray .also attach additional pagcs irncccastry.
roe muldple Injection or ran-water supply we1h OMLY with the same conttrrcrrnn,you men
anhmlt one form, SURMi7TAL iNSTUC't'iONS
9,Total well depth below IgDd surface: 160 _ _ __ (rL) 24a.Por All Wells: Submit this form within 30 days of completion of well
For mr/1101r.wr I t list all deprhr ljdl,(feremi(example-3@200'rmd 2®1001 construction to the following:
lo.Stalit water Revel below top Of eotsing' 63 (ft.) Division or Watcr Resources,Information Processing Unit.
!V Oilier I—1 is obnve tatirz utr"•1" 1617 Mail Service Center,Raleigh,NC 276994617
11..Borehole digracter: 6 _ (111.) 24b.Por inicetlnrti WeOs ONLY: In addition to sending the form to the address in
Air Rota 24aabovc, also submit a copy of this form within 30 days of completion Of wee
12 Well construction method, construction to the following:
(Le.nuger,rntgry,cable,direct push,etc.) —
Division of Witter Resources,Underground injection Control Program,
FOR WATER SUPPLY WRI,LS ONi.Vi 1636 Mail Service Coater,Raleigh,NC 276994636
13a.Yield(gpm) `� Method oftest:Air 24c.Por Water Supply&injection Wells-
Also submit one copy of this form within 30 days of completion of
13b.Disinketlon typa:MTH Anwvnt.8 Oz well cortsttucdon to the county health deparUpent of the county where
constructed.
Form CW-t North Camlind bepanTrmnt of Eovironmeot and Natural R,csourcea-DMalon of Wator RmM.1reel Revised Aupttst 2013