HomeMy WebLinkAboutGW1--00480_Well Construction - GW1_20240116 1
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.. WELL,CONSTRUCTION.RECORDIGW-1) For'Internal Use Only:
1.Well Contractor Information: 1 .
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Gary Thompson . , -14.1VATER'ZONER.,':'-1 -...-1-.:..1..;-:--•:,-..''.:".,••,.'_-"7•'.. ."- .'-- ... .•... .•...,
. _ FROM ' TO - DESCRIPTION
Well Centimeter Name '
4418-Ab..1 ft'. .161.4- ft* oath --41 1 0610Pry
. -- -
ft.. 1 1
NC Well Contractor Certification Number
•IS..OITTERCASING(for MultharediViells)OR LINE R(IfW1Sea le) . -'-• .' :7'1,..
Aqua PAL Inc FROM TO ' DIAMETER I THICKNESS MATERIAL •
compan Name . - .6 ft- Os- ft, 4/7i..4-1,11,. .so.p:u.
y
'.16;INNERCASING OR TUBING(rietitliit Mid dcced4o014,".''.".,--"---•-•--,"--'. .-i,.-•-; .
2.1lVell tonstructIOn kerndt#:' -19 I 4 .FROM TO .DIAMETER .THICKNESS MATERIAL
List all applicable well'eonstruetron permits(i.e.,WCOuno,state,Variance,etc).- - ft: ft.
-• ft. !'II' '4.Well Me"(climek well use): ft.
lk Water Supply We •17.-SCREENA.--....;',.".-'-J-..--.:-._L.-:" 1":-: ....: .,-...;:,:-L:1-,,. ji;,..•-•`.-.-;•---,:2'-.,-....:!::.,CC:
. FROM; ' TO . DIAMETER SLOT SIZE THICKNESS MATERIAL' ,
DAgricultural ",DMiCipal/Publie fL it. In.
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Opeotheriail(Reating/Cooling.Supply) IR .,:•clential Water Stipply(single) ft. IL In.
Olirdastrial/Commercial• " 13Residential Water'Supply(shared) .18.GROur--,--_•.:.-',.•....• ...: .--. , -2-.:..„........: - ...t.-:- .. .'- - ---;-.'"-•--•,.
Illtrigatien . . FROM. ;:''TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
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Non-Water ciSupply Well: ' 40 ft.' 71.0 ft' ta e'uttiv'):1-4-. puke- 1110.Monitoring 011=ovary a.' it. Gliop g .
Injection Well: •
ft. fL• .
DAquife.r Recharge 'E3Groundwirter'Remeditition . . , . . .
ElAquifer Storage and Recovery ,DStiliiiity Ranier FROM ' :•TO MATERIAL .EMPLACEMENTMETHOD
Aquifer Test DStormWater Drainage IL ft. •
D Eiclieriniental Technology ,DSubsidence Control 'ft-. - ft.
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OGesathennal(ClOO'Loop) E)Tracer • •20.DRILLING.LOG'(attieh additional magma ff neetisary),:" ,....,-:-: •.,.,_.-,:::--1.•, -
- _',.MOTION(eaten harden&'aro&W42111131 en,de.),
riGenth 1 alcating/Cooling Return) nOther-(dxplainluidiri#21.Rernarica). FROM TO .
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4.Date Well(e)Comple IS 'r`V't . *AIM. l b ft' I oa_ ft• . S 6,-.C..v.ny So.-
I Da it• 1)&0 M Ae,a.i e L'il I e. .
5a.Well Location: . . . _ .. - , ...
D.- b •A- • ft. ,. :2 •j,
Th1N",,4 itKit.“, _ . 1)..- tr .65 C.,ri44”r e . -.(-- r •••''.1 T''''-'7.,.
• - - 4.1,...' ,, ill--- "e• .
,
%Unity/Owner Nagle facility MU(if appliCtible) l 26 ft' I-Al: ft' C.f•U'el...t e- ' L.' 4.--Li-
IL
ft. .
1411•A'rC,011X., NZ-. ft. .. .. . JAN 1 a 202A
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Paystiall Address,City,and Zip ft.
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•S ii km& ' •21.-REMARKIII,1..r".:i.".•-..:-,-.-.•,-.":...,i-•••:-.:-...?:..•,,• I . :I `-1-'''.'..•`.'''•"l•' •,-...'.•;;-'4,1q4;1-5/.Ur
LArt:Qt2;0(4
County Parcel Identificialen•No.(PIN)
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Sb.Latitude and longitude in degreethifinidea/Sectinde or dedmal degrees:• .
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:(irwell:field,onelathong is suffielent) 22:Certhicationt
/ )t '
N 0 571rre •w .„ ,4 ,. .
6.1s(are)the Well(s)Micrmanent, or‘13Temporary . 3:..-•.!. .. of • .r.lrivel.M9cmr ' '
1, Date
By airing thit fermi.I hereby cat&that the latil(s)was(were)constructedln accordance
7.•Is this a repair-to an existing well: 3Yes or No with 11A NCAe 02C.0100 or ISAINCAC 02C.0200 Weltranstruellon Btandardp and that a
Vika Oa Papal!,fill out known well conitnialon Information and eralahi the nature ofthe copy of this record has been provided to the well owner.
repair ander#21;retharkteectlati Or on Utak&°filth fon*
23.Site-diagram or additiontilvell details:
8.,ForVaprtilie/DPT or Closed-LooP.Oeothermal Wells having the same You may use the-ha*of this page to provide additional well site details or well
construction,oily]OW-1 ia needed. Indicate TOTAL NUMBER of-wells Cot:sat:Clio;details,You may also attach additimad'pages if necessary.
drilled; - .. • :
fiUBM1TTAL INSTRUCTIONS
9.Total Well depth'below laid surface: 2,D••• -... .
(ft.) 24a.For,All Wells: Stara:this,ferri:within 30 days of completion.of well •
FOrmuldple weltslist all deptlis;Ifdifferent(eiamale-3@200 42..05 consmktion to the following
10.jStirtic water level below to of casingr. . (ft.)'
Divide:sof Water Resources;Won:Mb&Processing Unit, . . .
aster local is.tihtive.cthIng.we'"+" 1617Mall Service Ceiteii:Rahigh,NC 27699-1617 -A4,
11,Borehole diameter: -- 6 (im) 2411:FOt Inieetien Wells: in additionlo sending the form ta the:address in 24a .
_. • above,also subMit one,copy Of this'form within 30 days'of completion:Of,well ,
12.-1Weltainatilittlett method: i.t.i,6-r9 'Fri-r-_ . construction-to the following ,
(Ie.,auger,rotory,,miby.direct push;etc.)
Division Of Wider Reiources,Underground Injection Control
FOR WATER SUPPLY WELLS ONLY: 16361V1a11 Service Ctiter,.Raleigh,NC 276994.636.
v% 1- I
• 13a.-Yield.(gpm) .1,b' Mitlied Of test: C14 I-4-,Li ‘,,-r.-e. . 24c.For Water Snoolv&Iniection Weill: In addition,to sending the form to
. the tuldresges) above;alio submit anal copy of this Sinn.within 30 days,of
isb.Disinftdion type: :gx-14.7 or,- &noun!: ( to 942_ .. completion of well constructiOn to the leeway health.departmemt Of the county
where constructed.
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Ppm'CiP/51 North Catolina Depintinent oiHnvironnunnal Quality-ttivislen cif Water Resources , Revised 2-22-2016.
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