GW1--07739_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Infor atioq: ,
�`,S ,i O rQm,, r 14:_WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 0 /0 '
fif..1 9 ft. it t.J71T
NC e Co.:,a.. ctt lrieu[m A`urtrer _ "�jt /��� •15:OUTE-R!"=48!rIG:(ferr tun-.s..ell:w-lfs)O1 .4NER=fifapp1icH e).' -.
v (-I t (Q I °D) 0` e..B f ar iY L.d>J ft �[ ^ft. v + m I a
LI 1 �;a�i•244,
Company Name 1 16:INiVIIR:CASTNG OR TtTBIlVG:{dcoth a+l sloseif 7utlP) V
9.
3 n °co®I e FROM TO DIAMETER TIRCKNESS MATERIAL
2.Well Construction Permit#: tJJ ft. ft, , in.
List all applicable well permits(i.e.County,State,Variance,Infection,etc.) ,
ft. ft. in.
3.Well Use(check well.use):
Water Supply Well: I FROM I To I DiAMErER 1 SLOT SIZE i THICKNESS i MATERIAL
n A s�rrirxtlfiirai I711.1unir-.iptl/Riblic .- ft
_ ft In. ___
D(ieothermal(Heating/cooly-is Supply) l fKesldentiai Water Supply(single) '• — I
= j [[ . --' j I I '
nlSo=tIO1T .To. nu❑Industrial/Commercial ❑Residential Water Supply(shared) . ,
p EMPLACEMENT j oD&AIVIO NT
Non°IrriWater Snpply Well:gation P ft, Z 0 ft. De-b1 411 t rQu l l�/'
ft it //
ClMonitoring ❑Recovery
Injection Well: ft. ft.
.i19.SAND/GRAVEL'PACK'(ifapplieable) . ,
°Aquifer Recharge ❑Groondwater Remediation ;�•: .-
�Aquifer Storage and Recovery 1�Salinity Barrier FROM i TO I MATERIAL I EMPLACEMENT METHOD -
• _ k Ca_ i j 1
'LJJSy'wJcf iwL Lib LA."""""L.a.'" " ft. I ft.
❑Experimental Technology °Subsidence Control
-20 DUILLING:LOG'(tittnchaddlttanat.shetttifnecessors);; _
❑Geothermal(Closed Loop) °Tracer FROM •TO DFSCRD'1'rON(whir,hardness,sail/rock type,urnin size,.ere)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#2I Remarks) , 0 ft. /00 4L lay
4.Date Well(s)Completed:1° 3 1 23 Well ID# eft5'� 0 ft. !r- w n rock
5a.Well Lo ation:
s.._ �� I_ t le 1 tft• `Z-0Oft• row h k`ftt
erg,.; .._.__._- ---.____..-..___._
Facility/Ow"neerName �/ry Pa-ilityiDl(if applicable) ft. ft.i I,'••:**/-"'' ' .--'s'• Pc'---Th,
"' r
Xe
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Physical Address,City,and Zip D.f !) `• t'LI1 • .
4&s in 2.737(�co a.SS.�T �l ll nlalalcs
County Parcel Identification No. _
..• ' `:y i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: n
(if well field,one let/long is sufficient) 22 Certification: . !l1 y! I
N W f✓j� fot31!
Signatu ofCe�tt ed Well Contractor Date
6.Is(are)the well(s): Permanent or °Temporary By signing this form,i hereby certify'that the wellfs)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or IINo copy of this record has been provided ro the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
T•nr•mviNnlo Jn ... ....L. ..l6 nut.._
n.III w s.•r.r•V MT0TV le-.•r."nice
9.Total well depth below land surface: �°11 (ft,) 24a. For All Wells:`Submit this form within 30 days of completion of well
For multiple wells list all depths lfdierent(example-3®2200'and?WOO') construction to the following:
} •
10.Static water level below top of casing: �`0 (O,)- Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Air r6+6i1 24a above, also submit a copy if this form within 30 days of completion of well
12.Well construction method: / _-_ construction to the following: i
✓, ...mua.. ..0...JL....0 pp..O.o... ..us.a...,
FOR WATER SUPPLY WELLS ONLY: ,, / 1636 Mail Service C
, enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 06 I,d l9V 24c.For Water Supply&Injection Wells:
1 Method of test:
fw f t Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: r l I i Amount: -a t well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water+Resources Revised August 2013