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230 E Maple Ave (2) WELL CONSTRUCTION RECORD For intetiml Use ONLY: This form an be used for single or multiple wells 1.Well Contractor information: S. ._ '4.�W TEiaiZANES'_:,::. .+:':':_�'�...'4•.b ; = .•:. .. '�.._•-:,,•,- .. Lar' ,) . R{h FROM To DFSMrnori - Well Comtact Name fr ft 3536 R ft NC Well Cok=or Certification Number15.©IF1Ett:CASRYG' FROM TO DIAMETER TFRCMWSS MATERIAL Co,np.6Name. I&,UVMRCASMff 368 fr - FROM i TO I DGMETER TRiCKIW55 I MATERIAL 2.Well Construction Permit#: 3X4 Z R R in li.st oll oppltcable u e/i permits(r.c County-tram Yarkme.Injection,etc.) R R id 3.Well Use(check well use): .5CREFX. .. Water Supply Wdi' FROM TO D4IMETER SLOT SIZE THiCKHE55 MATERTAL ❑Agricultural ❑MunicipaliPublic R R ❑Geothermal(Hbating/Cooling Supply) 0 identical Water Supply(single) - R- ❑industrial/Commercial ❑Residential Water Supply(shared) FROM TO 'MATERIAL EMPLACEMEMT METHOD&AMOUr' Mirrigation Q R 3 r'Rr. i al Non-WaterSapp)y Wen: ft R (�(/r ❑Monitoring ❑Recovery - Injection wen: — , R R ❑Aquifer Recharge ❑Groundwater Remediation 39icawaur_uasrr t.P t; :'::....:_: • ._:':+... ._.: .:. ❑Aquifer Storage and Recoven• ❑Salinity Barrier FROM R TO MATERIAL EMPLACEMENT METHOD fL ❑Aquifer Test ❑StormwaterDrainage R ❑Experimental Technology ❑Subsidence Control _ ❑Geothermal(Closed Loop) G7Traeer FROM TO DE,SCRTrFl0N(coiw.bwduess *opt, .*mow-ere) ❑Geothermal(HegtingtCooling Return) ❑Other. lain under#21 Remarks). fL R • • R ft 4.Date Well(s)Completed: 7�9��SF wen DD# R IL ✓ Sa Well Location: ft ftP ft ft: Facility/Owner Name Facility IDA!(ifappfiable) R R 2 3o 46'. A a ale, DF • y R fL Physical Address.City.and Zip - County '' Parcel identification No.(P" - 5b•Latitude and Longitude in degree"uvtes/siwuds or decimal*degrees: 22.Certification. (ifwell field,one lat/long is sufficient) l_ - N ErO .S.S J. C. W / Signetme �. r Dai 6 Ts(are)the wen(s): erlaneat or ❑Tempora By this form,I hereby certify rhat&-u•r11{L was(were)constructed in occorrla. W&hh 15A NC:AC 020.0100 or 15A NC4C•02C•.020OWell CAmowtion Smndardc and tho 7.Is this a repair to as existing well• ❑Yes or Mlo copy oftis recad has beengtnided to rix well owner ffthit h a repair,fill out Anmm well consvwijon hjormaoori and explain dw naiuie ofdm repair rider•21 remarks section or on the back ofiNs forft 23.Site diagram or additional well details: You may use�the back of this page to provide additional well site details or w &Number of wells constructed construction details. You may also attach additional pages if necessary. For multiple arection or non-w•oter�y wets ONLY with the were commucti n,yarn can submit ore form SUBMITTAL iNSTLTCTIONS 9.Total well depth below laud-mrfacer- r o�d U • (fti) 24a. For An Wells: Submit this form within 30 days of completion of w For multiple w e11.s lar all depths tt(drfferenr(example-3(x)200am12@1001 ,construction to the following 10.Static water level below top of casing•. d M) Division of WaterResonrtxs,Information Processing Unit, !f waterlerd is obore eosing use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter. �Sr' (in.) 24b.For Infection Weds ONLY: in addition to sending the form to the adds A 24a above, also submit a copy of this form within 30 days of completion t 12.Well construction method: llr.;,— construction to the following: (ie.anger,rotary,abledirect push,etc.) Division of Water Resources,Underground iajectioa Control Program FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center.Raleigh,NC 27699-1636 132•19eld(pm)_ 42 Method of test: A21 24c.For Water Su4b&Injection Wells: Also submit one copy of this form within 30 days ofcompletion of 13b.Disinfection type: Amount: �� well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environnmt and Natural Resotucu-Division of Water Resoufm Revised August