GW1--04886_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.wi Contractor Informed :
J •
wdlCe cterNmea PROt4 TO eteeten ON
2O C_J ft. Hn.
NC Well Cow Certification Number
Sim e.47f c atd f!d 6,^ ft. ft. Ia. �-
y Nam , C�t� ,.;
. 6d1.�8, /yr,
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2.Well Co>atr.t�e Permit(P: � � 1> ro as srnrrtttt. . .
List all applicable well construction permits(l.a.UIC,County,Slate,Variance,etc) R. a. , te'
3.Weil Use(cheek well ice): ft ft. in.
Watermply Well: MOM TO MAW= lie!flifti Tanzman ' IdAIIMN4
.111 Agricultural DMtmicipal/Public ft, ft. is
■isothermal(Heaihn/Cooling Supply) .. esidential Water Supply(single)
ft.. ft la.
s,Industial/Commercial ctResidential Water Supply(shared) *' '4
'itri>zation Panes' TO MATT AL nett 'Jak1UODaAMOUNT
Neu-Wake Supply Well: It, ft.
Recovery ft ft.
=.r. — —
get barge DGroamdwater Remedietian
ii,Aquifer Storage and Recovery Selini Barrier e .p . '
ty PROM � &tATlL81AI. gittrdJ►CR.MerV't'MA9HOD
'/,Aquifer Test OStonnwater Drainage ft. ft.
•■ '...:' - Technology OSubsidemce Control tt ft.
if i...•i.ermal(Closed Loop) OTraeer X.lft211=ING* Q efell ro d*tiiiAt"'.1`
^ai.•-,., . coo',:Rerun ,•Other „rain reeler#21 Remarks PROM TO (War,tuimw.o cyse,imam r de.)
' et. rt
4.Data Watl(s)Completed: Well IDS `. •
Se,.W¢ID Leon:` 1t. PE' ".r^�a�� ._ = .
ficility/OwaarN ,. , ,. , , .F KDV(uapp ls) f fl
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;.li //U/ �✓�fC S� f� tt 9z'
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Phyeipel. City and Zip -.- - �y��.1., "'�
:a:
Conety. Parcel identilcatiee No.(PIN)
Sb.Latitude and longitude to de reesfminutealseecoonnfde or decimal degrees:
(if well fold.nee is sufficient)N ✓!!/4 W 22.Certification:
l f) /I Xa Q
L-22=
6.Ie(ars)the well(e)dPer +eat or °'temporary Sigmcne of Cottifled well r
By signing this form,.I hereby aertj that site well(s)wwzs(were)constructed la accordance
7.Ia fide a repair to an oiiadag well: DYee or o with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standar&s and that a
If ids is a repair,fell out known well construction informatimt eaqilain the nature of the copy of this record Wag name pmvided at the well owner. ..
repah:o+dsr#21 rennin section or on the back edits form. 23.Sits diagram or addlCionrd well deta!!s:
8.For GeoprolrPT or•Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,rely 11a is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
chilled: �!/�
/l` $UBMI7LTAL INSTRUCTIONS
!.Total well depth below bard /d surface: l) (L) 24a. For.All WAVE Submit this,form within 30,days.of completion of well
Far wills fits oil depths(*fit(esampk-34200'and 2®1001 construction to the following:
1�Stalk water iced below bop of ate: Q (ft.) .' , .. Division.of Water-Rumors;Information Promising Unit, ••- .. .
(fw eke tewi O seeks owing area +'
/ Mail Service Center, NC 276991617 ..... •
l fl61 Raleigh,/ ) :24b.For Inl W In addition to
geflon AEI! ..�.., __. sending the form to the address ia_24a
- . : _., ',above,also oubtait:one- of Chia form within 30 days of completion of well;
12.Wen Sit :.. .. t$ SPY
(i.e._auye'arstery,cable,direct pw6,etc.) 'construction to the following:., _
•Division of Water Resources;Undemo �turd ..n Control _ _
m:.,.',
FOltit-WATERSIJPPLY WELLS ONLY: 1636 Mall Service meter,Ralf_ h_.,NC 271636 _
13a.Yfeld(�m) ' - a D. >bfl of fist:,/'mod 24c.For Water Saner&Inlecd,a Walk:. In addition to sending the form to
_ ) the address(es) above, also submit one copy of this form within 30 days of
13b. n type: gat 1Amount:4,1,..A—..._ completion of well construction to the county health department of the county
where constructed. i 1
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Rewraoes 1 Revised 2-22-2016