GW1--03620_Well Construction - GW1_20230526

Tint Form
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1,WeU Contractor Information:
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FROM TO DESCtt�TION
Well Contractor Nama k, ft.
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NC Well Contractor Carliitiiosttion/Number 15•' 1t•C' .G.f6r•m �CaAe ivblLt OTt R•if a _
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yV a G! j�L �J✓fit CO, FROM ft T 0 DIAMETER in.
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CompanyN s ,• ':C• IIAD edt ermmT•o ll d=too
I.✓Z 3- FROM TO D1AI'1ETER TDIC[WE88 MATERAL
2.Well construction Permit#: — ft. ft. im
List all applicable rvell conslruo(lon permits(Le.WC,County,Slate,Variance,elo.) ft,
ft.
3.Wen Use(check warm use): 1
Wstar Supply Well- FROM To DIAMETER SLOT SIZE 7111 dEs9 MATERIAL
Agricultural ,®Mua(oipaIftbllc ft. ft.
Geothermal(HeatinglCooling Supply) JaR@sidendal Water Supply(single) h, ft.
�31IndustrlaUCommerolal [3Rosidendal Water Supply(shared) is..• rr
FROM TO EMPLACEMENT METHOD&AMOUNT
Irri anon • 0 ft. Et. p� 10 G
Non-Water Supply Well:
Monitoring Recovery ft. ft.
InJecdon ell: ft, ft.
:.)Aquifer LJ Recharge Ciroundwater Romediation
19.SAND/G ''YEL FA IE CATERAAI.11 a le• EMPLACEMENT METHOD
Aqulfer Storage and Recovery ��•.Salinity Barrier FROM To MA
p•�tstorrnwater Drainage
Aquifer Test .f_l ,
:i'`Ji•' [33ubsidence Control
Experimental Technology Oi, s
Geothermal(Closed Loop) E)Traeer 20.•D L—T OG. Hach it H n :sheet:ifneeessa
FROM TO DESCRIPTION color hardness soWrock sire eta
Geothermal Heatin Coolie Return Other(explain under#21 Remarks O C 0 H, 001 1
4.Date Well(s)Completed: y L4L 02 3 Well ID# %
' I tt. `� y r 7
5e Well Location:
it. h. 9 1
Paciltty/Owner Name
Facility U)#(if eppUcable)
Ph sisal Address.City,and p
Zf. ARIA
�fk� ,rd
County Pascal Idontitloatiou No,(PEN)
5b.Latitude and longitude In degrees/minutes/secon4s or decimal degrees*' 22.CerHl! on: '
(Irwell geld,one leviong is suffioloot) i
35.�le w
ZG�9 N �sr� FfG67
ca.`
signature of Certified WeU Contractor, Date
6.Is(are)the well(s)orermauent of Temporary BY signing thls form,1 hereby ceri(fy that the well(j)was(were)constructed In accordance
7.Is this a repair to an existing wall: Yea or,� with I SA NCAC 02C.0100 or 1SA NCAC 02C,0200 Wall Cow(ruction Standards and that a
((this is a repair,fill out known well comimodon iplormalion and e No explain the nature ojthe copy ojlhls record has been provided to the lust!owner,
•rdpair under#21 remarks secitan or on(he back of this jornt. 23.Site diagram or additional well detalls:
You may use the back of this page to provide additional well site details or well
8,For Geoprobe/DPT or Closed=l(rooP Geothermal Wells having the same construction details. You may also attach additional pages if necessary,
construction,Only IOWlisneeded,'Indicate TOTAL NUMBBRofwells errunrrmmer.INRTRiiCTIONS
9,Total well depth below land surface: � 00 24a;For�Ust Submit tlils.form within 30 days of completion of well
For multiple wells list all dep(hr((d(Qerenl(exagtple-3(200'•and 2@100) construction to the following:
10.Static water level below top of casings• C) 00 Division of Water Resources,Information Processing Unit,
ijwaler level Ls above casing,use„+" 1617 Mao Service Center,Raleigh,NC 27699-1617
fi Boreholeelliabovec r: (�•) 24b.For InleeHon Wells: In addition to sending the form to the address In 24e
/_ Yy above,also submit one copy of this form within 30 days of completion of well
eAr12.Well construction methods ' (' construction to the following:
(1.e,sugar,relay,cable,direct push,eta,) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of teat* t r 24c,lL4 gat re SuoDiv&Iniecdon Wells: In addition to sending the form to
13a,Yield(gpm) n the addresses) above, also submit one copy of this form within 30 days of
rklQf'I Amount: 2 Coo S completion of well construction to the county health department of the county
13b.Disinfection type: where consbucled.
Revised 2-22-2016
North Carolina Department of Envlroamental Quality-Division of Water Resouices
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