GW1--05898_Well Construction - GW1_20230918

WILL CONSI'Rll("f1ON RFC()R1) (CW-i1 hnrIntcnuul Ilse Only:
I.W l Contractor lufort tiou:
(� �L ) 1'� �' +r 1� WATM.R'l(1NR9 _ w� ... .,. -M
a• ��MF'� i11OM To onouY11t1N ..,o
Well I.ontraclor Name __�."___-._..__,...�_.-
�C1)5C _ �
No".
NC Well Cuttuactor Ccttificatiat Number IS.OUTER CASING(for mold-eased wadsti*i f a t � - —
(,� MOM Tell DIAMETER 'flb1('RNWMA AI,
- xi— —- . )
(•ompa Name
_
!l- ft, la
I6 INNER CASING OR DURING tawlhrrraat clakd loop)
2.Well Construction Permit N: FROM TO DIAMETER TIDO(MI MS MATERIAL
List all appltcahlr well coma-whom permits fie.i/lIZ County,State,Variance,etc) .f I S n' rr n' [L/ L2� in.
t I G 11 L � r V_
n 16 n. in.
3.Well Use(check well use): _
17.SCREEN
Water Supply Well:
PPy FROM TO DIAMETER SLOT SIZE TIIN:KI5 5It MATERIAL.
Agricultural 0MuniclpaUPublic n. ft. la
Geothermal(HvitinglCooling Supply) Residential Water Supply(single) n. n. in.
lndussriaVCommcrcial Residential Water Supply(shared) 1R CROU 1'
Irrigation FROM TO MATERIAL ItM►I.ACF.MENr METHOD&AMOUNT
Non-Water Supply Well: U ft. 5- " ft. bat ci.o' ),..'11C . 'L!'Y\�G1
on Mitoring DR., ft. �+ ft.
Injection Well: —
ft. ft.
Aquifer Recharge D(iroundwater Remcdiation ---
19.SAND/GRAVEL PACK(if app'l(eable)
Aquifer Storage and Recovery QSa}inity Barrier FROM TO MATERIAL EMrL►CEMH'!T METHOD._.—,
Aquifer Test tStormwater Drainage n n.
Experimental Technology DSubsidence Control ft. n.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DOther(explain underttll Remarks) FROM TO DESCRIPTION eels,.Imams.soR+nete>p�s.�+ ..I�_
�• ft. �ft.
4.Date Well(s)Completed:-2�l- 23 Well ID# n C) fL C (� (CA 'moo --
�� f
Sa..Well Location: ,, �0 n -�J3n 60(- ,1 47
( —Sr f ea'l i 01' _- _ tar `)v-Nee C5C it IL 1
Facility/Chimer Name Facility IDS ifapplicabk) fL n'
2yi .tie 4i Q . —rt. fL
E,z e .• _. ''\.i!--
(\yaical Addrns,city' td' (�
21.REMARKS '':f) j g ?Oi^
Y GU'11/ 1 J
County Parcel Identification No.(PIN)
IraJ;a`.7-.."':) t/'"" •5`4:'.9 i.'r..1
Mr.latitude and longitude in degrees/minutes/seconds or decimal degrees: CISi,':.!,'.-
(if well field,one latlbng is sufficient) 2 Certi w ti,
____-_.___ ___N W ,tun A % I - 23
$i a�:T..WellC..,,�°:* Date
6. !stare)the well(s)> Permanent or QTemporary
By sigrWg I •form,1 hereby eerily that wedl(s)wax(were)ebteuructed in accordance
7.Is this a repair to an existing well: DYes or No with/1A N C 02C.0100 or 154 NCAC 02C.0200 Well Construction Standard,and that a
If this is a repair,fill out known will construction information explain the nature of the copy• •. record has been provided no the well owner
repair under 021 remarks section or on the bark pith:fixIn
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
11.For Cruprobe/DPf or Closed-Loop Geothermal Wells having the same
constnlction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary_
Milled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land snrtses: 505 (IL) 24a. For All Wells. Submit this form within 30 days of completion of well
For lwdupie wear list ait depths if difjernir(erasapk-3®200'toad 201005 construction to the following:
10.Static water level below top of casing: 2-0 (IL) Division of Water Resources,information Processing Unit.
If water love/.s alum:.ciatng use`," 1617 Mail Service Center.Raleigh,NC 27699-1 6 11
rr /
I L Borehole diameter: ( ' 2-5 (in.) 24b.For IniexGon Wells: In addition to sending the form to the address in 24a
112.Well tvustruetion method: 'r r 1 1 C above,also submit one copy of this form within 30 days of completion of well
1 nM t/(� construction to the following
tie.auger,:Mary,.irk,duea push,etc)
Division of Water Resourees,l ndtrpranab Injection Control Program,
FOR WATER SUPPLY WEjdS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Ik Yield(rpm) ,,) .%Ietb xt of test:_) J _ :lc For Water Scoots, & Injection Wells: in addition to sending the form to
I_.; i the sdv��dr (<s) arrow, also subttv't one :, y of this Cam unthtn 30 days of
I is fliaideeetwt�yle= vneuuut: _-- ] :=.Jmplruon of well construction to the county health department of the county
4 .-----_—
where con acted.
Iona G ttv•i North Carolina Degrrtmmt dfaviro natental Quinsy-Divisusn of Wawa.Resources Revised 2-22-2D t 6