GW1--05889_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD (GW-I)
or Interne se n y, .........---
1.We11,Contractor InformatlQnt
...7a..)(Yl; :�u TO Dim''• i�
Well Comraolor/N/ame /� \� ft. ft'
4Cze / 1 ft, ft, —
NC We Contractor Certlflostlon Number ? Dd 1]lit+l''�ll�':Tl r]TCfiAii D T Y l�Ec;�']IIf1 I4:t}];]};lI ;j�]IY GIi"
IMMEM
y� PRO TO Dig Er(n,
C,��� s L��1 l��r _ ���' /� r) ,11,E s n
Company Name �� OTOR lifil<'!Jib'iIAL?ar4e i.til E)ChSF).1S`tlYPf'1' Y]�fltrlfi1�14A�i�'1�t
S24) 5/A14'z) / •r;ou TO ' ..„ Ilki:lc•
2,Well Construction Permit#t �' re, «, In,
!tot all applicable well construction permit:(be, Ut County,Stale,Variance,am) ft,
ft — In,
3,Well Use(check well use): • ( y(.I;T,� $i`,�"�:t4�, IV_'f� 40 6 z'�?'tr�i AM. ICKNess
e: u
Water Supply Wellt ft ft In,
Agricultural QMuniolpal/Publio , Y
Rosidontial Water Supply(single) ft, ft, In, .
Geothermal(Heating/Cooling Supply) � pp y
industrial/Commercial ORosldontfal Water Supply(shared) rinco1b mi6 t Rr`6''E'Atv`#33 r
Irrigationon
FROM TO p1A'rERTAL EMP ACEMENTMETHOD&AMOUNT
It. �(b f4 { /L ell! ;' 0 1 Lf r �jd d 6
Non-Water Supply Wells
Monitorin3 QReoovory it, ft,
Injection Weill It, ft,
Aquifer Recharge ®Groundwater Remodiatlon i.1,0•4t al,v i MOM" tiff!AP II DIMES.- MPLACBMMNT MTtiOD
IIIMNIMMIN
Aquifer Storage and Recovery OSalinity Barrier PROM TO IJA :w
n, , «'
AqulferTast ,,?. !; ( StormwatorDralnaga• — _
•
Experimental Technology 'v'` QSubatdonoc Control
ft. ft,
.11111111
Geothermal(Closed Loop) QTraoor PROM TO DESCRIPTION color hardest' wl rock .r •rein sloe sic,
Geothermal SHeating/Cooling Return) 1101W(explain under#21 Remarks) ft, y «, j S Di le,
4,Dalo Well(s)Corhpletedr 2J—b4S-aZ`t won ID# ft.
5a,Well Location:; < • . ft,ft, f4
Facility/Owner Name Paollity 1DH(Ifepplioabie) — T
•
3 ge_UaI�. 0 y, . . f4 —
ft, It
Physical Address,Clly,and Zip p n °))i
vi �Q i 11
County Perot IdentllleationNci.(PIN) _•.s
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees! 22,Cordite tiont
Orwell(told,ono IeVlong Is suMolont) •
'1 _ , 3 L N 0 ' W _•-• C�§-la' ''.
GtG(� Dale
Signature -=Certified WellContractor
6.Is(ere)the weU(s)�Permanent dr Temporary
By natures C jam, I hereby oe t(!y that the well(s)was(were)constructed In accordance
yes or ENo • with ISA NCAC 01C.0100 or/SA NCAC 02 .0200 Well Construction Standards and That n
7,Is to n a repair t u a n existingniwell; Qcop)of this record has been provided to the well owner.
(IOUs Is a repair,JI!!out know t well co/islrucllon ht/brmatfon and explain the nature ofrhe Site diagram or additional well detallet •
repair under lilt reinarkr_'eatlon or on the back of this form. 23
You may use the book of his pogo to provide additional well site details or well
NUMBER t e sa oonetmotlon details, You may also attach additional pages If lesite details
cony ruotlonronly I OW 1 e neeobe/DPT or ded,,oIhdloate TOTAL Wellsp'Geothermal havingthe ells
artunallTTAL INBTRUCTIO 3
drilled:_----- f--
Q 2 (fL) 24a. Her Alm VY 1liar Submit this form within 30 days of completion of wall
9.Total well depth below afd surfacer g,
For rnufuple wells Hsi all depths(fd(Qereru(oomph,.3®100 d 00� construction to the following:
(ft,) Dlvlslon of Water Resources,Information recessing Unit,
If1 terNc water level below top of casings 1617 Mail Service Center,Raleigh,
NC ress
n 24a
I i,Borehole level isabove terl.,use"+"
(in.) 24b.For In Weller In addition to sendingth 30 days of completion oaf well
I1, dlomoter: above,also submit one copy of this form
12,Well construction methods
d t61. y oonstruotion to the following:
(f,e,auger,rotary,cable,direct push,oto) Dlvlslon of Water Resources,Underground Injection Control Program,
• 1636 Mall Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY! rrrr�oston Wollat in addition to sanding the form to
i+ 24c,For W___ate:gbove)vals submitcopy of this form within 30 days of
13a.Yield(gpm) D Method of test: . iho e(os)
CO_ s completion of wall oonstntolion to the county health department of the county
C �� p{ Amount' where oonstruoted,
136 Disinfection typo' Revlsad 2.22.2016
North Carolina Department of Environmental Quality•Division of Water Resources
Form OW-I