GW1--05868_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD (GW-11 For Internal Wee Only: _
1,Well Contractor Information: �-
L QL C/ L ROM TO DE:�$ • 1•N
WellConlreolorD7eme J It. ft,
1/ 4 ft, It,
NC Wall Conneolor Cenlfloetlon Number •
;'t 'o i�jIKI 'i1 �7Irai iE Yz ? t.f117 4:tIl�E�l'sS(�'tiY:F PCIENIEIN TERIA
1 /' ' PROM TO DI M' E' +
i S //(�L Pk�-I YI� �f�, ThC tt, ��� 1
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CompanyN e �7 r 8 FROra {it Ttl `dTt t+ d.a O i it MOW n a:s h1'ATERIAL
Ls t 1 ! ft, In,
2,Well Construction Permit Th ft,
Gist all applicable well construction permits(i.e,U1C,County,Stale,Variance,etc.) ft _ In,
fb
3,Well Use(check well use): „T , '�
Liu'� f r `�DDI 8L0 8 ZE ICKNE88 A�
Water Supply Wellt •;o„ o
Muntoipal/Publlc rt. rt. ERIAL
In,
Agricultural � —In,
Geothermal(HeatIng/CoolIng Supply) geRosldentlel Water Supply(single) ft, tt,
Industrial/Commercial ORosldontlal Water Supply(shared) "f lY �olb�il�f' Ct l';'a` MAT
FROM TO MATERIAL EMPLACEMENT MET�D G AMOUNT
.,i Irrigation • L' fL (L �i I'L e ell�� �y _ /iJ^
Non-Water Supply Well: !,
Monitoring [ Rcoovory "'Infection Wellt ft. ft,
Aquifer Recharge ®GroundwaterRemedlatlon �r �r=''• '':- :'S�`x,','''`1`''''`'
t'>`9;hA l�pl Rs1' 1 iA�k!?dlMlg'lll MPLACEMENT METHOD
Aquifer Storage and Recovery' OSalinity Barrier FROM To ft 1 L!,
�'. �-s�Stormwater Drainage fo,Aquifer Test 1.2Y It rt.Experimental Technology
Return)
Subsidenol in until
Traaor l:;2 I4)Y41 3'146111,i0D«aft' INIRl. a R .e CI I .014A ,).',.' .•..rr,r:
Geothermal(Closed Loop) [ FROM TO DESCRIPTION(color,hardnerr,rolProek type,grata slat,elr,)
Geothermal(Heating/Cooling Roturin) [ Other(explain under#21 Remarks) L, ft •7,) rt. J 1`r i-S a,,,�_u rid /yi),,G/,„
> � Well UN r lt, C5�6 9 rArt I•e.. J
4,Date Well(s)Corhbiletedr`J1ft, ft,
Se,Well Location; -t. e `
•
�� n. ft. f.r.e
Q�� �I l r u s f-./till t��t 1-�- P J.a�•��� fL ff. n
Pnolllry/Owner Na /� Pm:4111yy IIN4(if eppllneble) l/r r �) j 2024
,'45<v (2,-) e r5 C>�F'g • r, ra ' I
Physical Address,City,and Zip a r,•Y'P'"'y �'`v`'r '
•
County
Parcel IdentllloetlonNo,(PIN) _•.s
—
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi 2Z,Certification:(If well field,one IeVlong Issuufficient) _
•
lam• VG L— t.
Signaturoot IQed Well CoNrac r 4LLL2L
6,ls(are)the well(s)SPermanent dr Temporary By signing fhb form,/hereby aerl(jy that the well(s)was(were)constructed in accordance
with/:A J.'CAC 02C.0100 or 114 NCAC OJC.0200 Well Construction Standards nod Mat CI
Is this a repair to an existinguswellwells [ YaB or �No copy of this record has been prcvlaed to the well owner,
If is a repair,Jit1 outkrtown well boprrue stton GVbrmallon and explain the stature of the Site diagram or additlonai well details:
repair under NJ relnarkss4ctlon or on the back of(his form, 23
•
• You may use the bank of:als page to provide additional well site detelle or well
8,For Geoprobe/DPT or Closed4Loop geothermal Wells having the same construction tithe b, You may also attach additional pages If n else der
construction,only l OW-!!e needed. I}tdloate TOTAL NUMBER of wells enBM1TTAL INSTRUCIIQ
drilled:____----___ `
�J 9,Total well depth below land s (tt•) 24a, For All W eller Submit this form within 30 days of completion of well
rent(e t
For multiple walls list all depths(rd(Q'erarl(example.3Q200'and 2g10n consiruotlon to the following:
2L, (ft,) DIvlslon of Water Resources,Information Processing Unit,
If tSer level
water level below top of( casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
Uwnter level Is above ca,ring,use"+"/
�_�(In.) 24b.E^x r„laarion Wells„ In addition to sending the form to the address in 24o
11,Borehole diameter' above,also submit one Dopy of this form within 30 days of completion of well
l
`�, ✓ I ✓ construction to the following:
(i,o Well construction
,auger,rotary,cable,
methods direct push,etc) Division of Water Retwurcee,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: a relectlon Wells: In addition to sending rho form to
I r 24a FStC '"""""" of this form within 30 days of
13a,Yield(gpm) Method of testi rho address(es) above, also submit ono copy
L, completion of well construction to the county health department of the county
136 Disinfection type; L t . t^ / Amount: whore construoted,
Rovleed 2.22.2016
North Carolina Department of 13nvironmentai Quality•Division of Water Resources
Form O W-I