GW1--06762_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
•
This farm can be used for single or multiple wells For Internal Usc ONLY:
1.Well Contractor Information: ` i
M t K42.-. .VL. IN/Will-6 tFR WATER zoNrs• .. ,.' . , ..,:n.•:
Well Contractor Name FROM TO DESCRIPTION
I da Q 266ft AP4tj ft. II -Prk
ft. ft.
NC Well Contractor Certification^ Numbs .:1V.OUT. R CASING'(for.'mnolh:eused Wells)"ORL•UNER(if up'p1iebblc)'•:i"."'
1 „�,,� �� � WELL
_•J��•�at, , FROM TO DIAMETER THICKNESSD MA E�RI/AL
l Company
!J 1 f/f r� +i fr. I q9 ft. I I (�"` DF.rr2,l V�::r
Compm,ylJama ) �y .'46INNER'CASI/NG`OR.TUDING`..(Reotliormal•alhicdloap)'., ` ••. 's: +;... •.•
2.Well Construction Permit#: �S t2 1 mom TO DIAMETER / THICKNESS MATERIAL
List all applicable well construction permits(L e,Cototo;State,Variance,Mc.)
fr• ft, In.
3.Well Use(check well use): ft. tr. nt
Water Supply Well: 'AI:SCREENS:!r."tf•Ti" .. ...:i:::,:':r':,::Y•i:_:...:'1 :,;:i•.'!•:::..._, .:.•:,'•=::..•:
- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft. ft
❑Geothermal(Heating/Cooling Supply) ORgiTlential Water Supply(single) it. ft. is
°Industrial/Commercial ❑Residential Water Supply(shared) "•18r'GROUT(.:'' ::.i'`;.;.,..;-'.:;' .;,,;':`;",:',..:,;-•;-. .:.:.,:.:•.
°hTlgallan FROM TO MATERIA EMP,r�QCEMENT METHOD B•AMOUNT
Non Water Supply Well: 0 itego It /10k �Lt q ,/✓Lc.r
❑Ivlonitaiing ❑Recovery ft. ft. `J I t��!��
Injection Well: .
ft. ft, CPI -86 ,5 .�felat_
❑Aquifer Recharge ❑GroundwaterRemedialion ,:19:SAND/GRAVELTACIG(i ferinlienh16•.: -=';:.::;. ''`" `"
°Aquifer Storage and Recove rttoM' To ft. MATERIAL •EMPLACEMENT METHOD
°Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) OTracer '.20:DRILLING.•I:OG•(uittieli naditionahlfafirifri'ecassary)`; :,:.:;; .i•::, : _•• .._
FROM TO DESCRIPTION(war,hardness,salllrack t •..+•'•`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1/21 Remarks) 0 ft6.�itl R�aln size etc.)
ay
4.Date Well(s)Completed: �' 2�,'� (4$ fr. 7
ei ft. le— r ed
'G�
5.Well Location: it' / (�7' ft. cri,o T
'd 7'. 1► I I i�s 7 7 f 4/,16
RVt Cst'RNi �
Facility/Owner Name ft. ft.
Facility IDO(if applicable) •
. b o� V J..5 Need i�d M�1 s�v,tie der It:ft. tr. �:,� -V,..��_,
Address, =-- s :a�
Physicaless,City,and Zip if ft b•�. Z_'' ',
!_l N i e>J ;21:�1:>;1►•IAkk;>i;i- .. ,. ,.. /��r:TI• �`
County ••��'�:�" �F•/`I' •�' .. •,
Parcel Identification No.(PIN)
• If•,..,“ •^ram
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �, ;a, '4
- :.,.,t1 i it::,
awe!!field,one lat/long is sufficient). 22.'Certification:
�0"� �Zlz
.3r 5.0t 6. N gib'd243I W
3 _Q o -r46;L.3
6.Is(are)the well(s): crmaueat or enure of Certified Well Contractor 1 Dam 4Temporary
By signing this forte,I hereby cerrt&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: pyes or with ISANCAC 02C.0100 or 15ANCAC 02C.0200.lYell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under lin remarks section or on the back of ibis form.
� _ 23.Site diagram or additional well details:
8.Number of wells constructed: d IV You may use the back of this page to provide additional well site details or well
For multiple infection or non-water supply wells ONLY with the same construction,you can construction details. You may also attach additional pages if necessary,
subnnhoneform. 24.Submittal Instructions: i ,
9.Total well depth below hind surface: 1401
For uu ltiple wells list all depths lfdii It-different(exonnple.3Q200'andz !00 (ft) For All Wells: Submit this farm within 30 days of completion of well
• © 9 construction to the following:
10.Static water level below top of casing: 6t
(ft.) Division of Water Quality,Information Processing Unit,
•
If waterievel is above casing,use"+"
r 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: 1e� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: C�'' above, also submit a copy of this frirm within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: y
Division of Water Quality,Und Irgrouud Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 6 Method of test:_A (� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
�� the address(es) above, also submit one copyof this form within 30 days of
13b.Disinfection type: 1 obi= �e p p
Amount: "iY' ,� � completion of well construction to the county health de twnem of the county
where constructed.
Form GW-I North Carolina Dc
parmteut ofEnvironment and Natural Resources—Division of Water Quality
Revised Jan.2013