GW1--05664_Well Construction - GW1_20240920

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W ,I.,I a CONSTRUCTION RECORD --�.
'this form ran be toed for single or multiple wcljs "'•" for- P Intr.nlgl t)s ONLY: __ --_----- -- ---•—'"^'""'
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F'l.Well Contractor Information:
Mitchell De - -._..._.,_�- .�-�...___..— .
an Gook .Ia WATERJ0—NT's•_ . .---._.-_____....
Well Contractor Name •FR6M _TO '_ DESCR�TIi ._ -"""•'"-"""•-'•"---
20�3 A It.� )- 11.
ft, -It i^ ; ---�-•_-_�__....._. _-^
NC Wall Cuoaactc((,rnificasion Nwnbcr - � I -------
Dennis
15,OUTER CASING.•(for:multi ca ed•wells) RIENERSif:ap Ile e!Holland Well Drilling FROM TO DIAMETER 1 THICKNESS, �" "-""•
Inc, '" „•,•1 MATERAL^-_
�• ft. I
Company Name• - .__ -^ S/ a.., , ; �/1 in, .tom• .),� '
2.Well Construction Permit Il;_, .�.,� iH
••1'6:INNERC:ASINC OR.:Th1BIurii eothermal.clate:d7loonl.
1, all applicable well;tenons(I.c.Co- ":I'' S � - - � '�•�"_�-"",_ -
FROA1 -T(r' - D1AMF.'rF:R IL'KN MATERIAL
_.__-- ft ft. ' io.-
y,,Brute, Vnrianre,InjacNan,ntr..) - _ T•T,^ - - -- -
3,Well Use(cheek well use); - ' rt. • fr• io: • ;.
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WatcrSupply Wrll; ""_------- -._..,....__.. ._--.-_.__ _. - .,._._, ---
FROM 'fO DIAA1 F;1'F:R,: SLOT SIZE TIIICKN F.SS hl ArrF:R1AL
(JAgrirulture LJMsmic.ipal/Public rt. IL in.
l.ICleothunnal(Heating/Cooling Supply) 7 'idonlial Writer Supply(single) _ It. -^___R, • In,-- - — _
-- - __
__ - -Uh Industrial/Commercial LR idcntiol Water Supply(shored) 18ROUT"' ' TClILTI;atiOl _FAO ...'ra - hIArF•RIA . l _ Eh PI,A CEM ENT MtTIIDD
&AMOUNT...- - 4 , ft. 'ft. 10
Lj
Non-Water Supply Well:
n
l7Monilorinq Re IJcovery . eft r
Injection Wcll; _--------- ---_ ._-. - _--•._•- _ _ _g�� _ft. c i'� �. .�i^�-_� Ai-,Afl• ft.
DAquifef Recharge GGroundwnter R.emudialiun 19,CA'ND7CRAYEI PACK`/if:`e' Ii'calile
°Aquifer Storage andRecove FROM ' TO -ATE )``• --•T-- --•-----•--•---•
ry I;JSnlinity l;arrirf hATERIAt. •,��_- EMPLACBhi},•NT METHOD ,•,
OAquifer'I'est ft. ft.
L7Slonnwatcr Drainage - ^
❑L-xperiluenlal'fcchnolol.(y °SubsidenreControl ft' rt. -� "--_-
OGeolllernial(Closed Loop) .?Q:DRII LINO LO rtacti�aiiifitionel sheets if neck's ;
'�-"
p) L.•7TI'aCel': FROM__ TO DESCRIPTION color,hrrdaeaesolliroak t n1n size�edc. '
f lcoth ermal(Hcating/Cooling Return) LlOthcr Sexplain under//21 Remarks) •�~ z�,e 1 -
4, Date Well(s)Completed: r19., ft. ft.
p 7- 9,;;25tvell Inn / r �__ _� , • - __-. �..._._.�_._.._._._-..._ _-_--_._.
Sa.Well Locating; ft, ft.
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Facility/Owner Name ac""l[)0(if ap. ft. fr. SEr ��]] 024
Pnr.iJ,tvIDNapplir.ablc) __. ....__.. _._..._. —._.___.._.. .........__.__�.._..._..._.-_Sl__
f✓PAY 7` i Q -2,2 Y:._ C ,c1l..J, cy L.4i _ _ _•
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Physical Address,City,and Zip ,•_,.__1:1•,r'-%'it
Cuuniy Pmrcl'Identifcation No.(PIN) -_T_- __ . ._ _
Sb,Latitude and Longitude indegrees/minutes/ses onds or decimal degrees: _-_. __ - -___.._ "�T-"•T_
22,Ce.rtification:(dwell field,one Iadlong is sufficient)
,O,5 a .74,�t. ___ ,„-: �e'J"'IF A.('v w ) 't'a=_ e.Ll__- ei...._. _ d_i - e). O 9•- -,. o N s4
Sipmturr,of Certified Well Contiaator Date
6. Is(are)the well(s): l43-cfmanctit or flTemporary
By signing This Jorai, l hereby rert fy that the well(s)was(were)constructed in accordance
with I SA NCAC'02C.010U or ISA NCAC 02C.0200 Well Construction Standards and that a
7. Is this a repair to an existing well: °Yes or h}iVo�^ copy of this record has been provided Iodic well owner.
If this is a repair,fill on known well construction it Jornmtion and ecpluin the nature of the
repair widerillf remarks section nron the Flock 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
R.Number of wells constructed:_1 _ _ _ construction details. You may also(lunch additional pages if necessary.
For nnrbiple infection or non-water supply,cells ONLY with the.rarne construction,you can
ado,,,,(1nafornt. SUIIMITTAI..INSTUCTIONS
r,T _Art,) 24a. For Ali Wells: Submit ibis form within 30 clays of completion of well
9.Total well depth-below land surface:_•_
Fur multiple wells list all depths if different(example• l(3200'and 2C/00') cOnstrU0lion to the following: •
10.Static water level below top of casing:.,___ . ar?'-.__ ,__�__^_(fl.) Division of Water Resources, Information Processing Unit,
/fwater level ir above casing,,tse 1617 Flail Service(.'.enter, Raleigh,NC 27699-1617
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I i, Borehole.diameter: 6"_ _�_ —(in.) 2Ib. For Injection Wells ONLY:; In addition to sending the form to the address•in
Rotary 24a above, also'submit n'copy oil iliis'limn within 30 days'-of completion of well
12.Well construction method:^_� construction to the.lirllowing:
(i.e.auger,tritely,cable,direct push,ale.) _.__ .._�.-____ :, •
:• -- ••. .
__ _ _ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �_ ^-T -7--- . _ 1636 Mail Service Center,Raleigh,NC 27699-1636
- Air lift 24c,Ivor Water Supply&1njection�Wells_ .
13a.Yield(gpm)_.,_ 'Q
Method of test:
Li Also submit one copy of this Corm within 30 days of s mnplchon of
13b.Disinfection type:„ _•.,_ well construction to the county li eIth department of the county where
Amount:1? Oz,._....___._......_. i
-- :___- __ _ constructed.
Form(1W.I Notth Caroline Department of Environment and Natural Resources•-Division of Water Resources Revised Au[usl 2013

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l ` f CONSTRUCTION TOTAL LENGTH #OF LINES MIN SPACING MAX DEPTH WIDTH' DISTRIBUTION SEPTIC TANK PUMP TANK AUTHORIZATION 244 1 i
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N aof t(le NC Lawsfand{RKifes4forSewage Treatmentand Dis osal and;folthefegndItlo st.P�thl e p WI h•theiprovislons s''' r,
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J „ , r fand11959 are Incorporateditiyfi,-,,, ce Into..this a mlt a " J t 9 2,r 1954, ]955�:.•c
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