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HomeMy WebLinkAboutGW1--06306_Well Construction - GW1_20241022 WELL CONSTRUCTION RECORD For Internal Use ONLY; • This form can be used for single or multiple wells • 1.Well Contractor Information: 14 tY4A I ER ZOh)LS G, a FROM ,TO } DESCRIPTION P itli Pobk ti ..• Well CoutractorName .1, ft.. ft. II i!. A ) I5;'O1)tL+R C SSI`IG.(fo:mstilte-A arc tcvci l tL"T k4c{c aAptL as�bl7 ;t NC `SContracto LcrtL tioal�i ?�: � -I- Plieir t 1• co�nr lT rn 71 ��tl. � ' C (� �/b 4'd We I6 IltlNEICOASiNG-ORSIVIMO(R akliied-kihP),', Company Name i (%�� > �� 2.Well Construction Permit#: l'� FROM ft. 5 TO i f DIAMETER THICKNESS MATERIAL t 'in • • Liu all applicable well permits(i.e.County,State,-Variance,Injection eta:) ft • 3.Well Use(check Well use): IR FROM .1 1 MATERIAL FROM TO DIAMETER SLOT SIZE J THICKNESS I Water Supply Well: r ' a t I C3Agriculraral 1'J+ unicipal/Public r h �° C.1Gcouieuu81 IneaUfl ._UUIUlg'aupply) • 1acunal watel supply(single) t •:1S_:(iROUTT EA>p'I.ACEMENT METHOD&AMOUNT QlndustrialCommercial OResidential Water Supply(shared) 1&G To. atA °Irri 'on :.. . r��aterupplyWelk ,"I 0, R' La s..... R I;�d Oivtotritoring °Recovery g Injection Well: .., °GroundwatecRemediation i9 SANDfGRA'V4ti.Y'a1CI f{faupll biO . °AgpiferRecharge 1 Timm p'rn j .ra. .i.. - uwqutner nrorage ana►recovery usaimtty Burner 13 ft- 1 ;, } _ - t � � : ft. 1 ft. • 1 ❑Experimental Technology ❑Subsidence Control • Zu,`pin O.ti ;4 hsrlditlonnisLeets'ifnec aa►r);. °Tracer FROM TO DESCRIPTION(calor,hardness,soilfrachMMpe.t�she,etc.) ['Geothermal(Closed Loop) ft.- '� �!Q ❑Other(explain under#2l Remarks)i; QGeothermal(Heating/Cooling. alum) b' Z 2 eft .. a?0.t. 5(J. e,- ro c - 4,Date Well(s)Completed: we1l3D## it.- ft.- 5a_>BellLocation: _a f•la•fl �0ib� :. -1 : _. . � Fa ty/Owner Name Facility TM(if applicable) ft fL ' , -✓' r `155$ ,I4gig S/14ay all L_IukC `r ft. -6�� t0?4 Physical. dress.Ci and Zi d:xt:SEnt1BKS ., -%u County Parcel Identification No.(PIN) _ 5b,Latitude and Longitude In degree Jmluutec/seennde nr decimal degrees: ;, ,„�,;,,,,:;.,9r Petfee'L-1 .:t ^ 4 (it wetl�el3,olle]aUlor(glssrftha+eeT) , A 1�' A �3 �N W ` ( E.* De ff Signs� of Certified Well Contractore 6.Is(are)the well(s): q/Yermanent or °Temporary By signing this form,I hereby cent)that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: °Yes or fiNo copy a/this record has been provided 1+,'the well owner_ ff this is a repair,fill out Brown well construction information and explain the nature of the 23.Site.diagram or additional well detnr'1s: repair:mtler#21 remarks section on the back of this form You may use the back of this page to provide additional well site details or well EL AT___i-.. ,fc cot:--_eavneee't _I construction dettiils. You may alsn attach additional rage.ifneornsart Far rar+hiple injection orton-wateraupltlyr'elliManville the same constrection.youcunt elitirkwyrA1 INC{{r!T7/lA*C 9.Total well depth below land surface: 4 '( (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3(a)200'and 2Q100') construction to the following: ' G+0 (ft.) Divis►on'of Water Resources,Information Processing Unit, IQ.Seatic water level bgow use"+`"top of casing: I .Mail Service Center,Raleigh,NC 27699-1617 Jf water Tavel is above casing 24b.•For Injection Wells ONLY: In addition to sending the•form to the address in 11.Borehole diameter: r (in.) �y 24a above,.also submit a copy, of this form within 30days of completion of well i ; �q&r r®rotaj- w+,auusii.0 iv w..foiovtit :, g.wren construction meiiiimti: I _ (i.e.anger.rotary cable,&aectpwh'atcj >u,r�,un Ux crate.s cavuassa,ouncegrnoun>ulnauuuwuusnraugrutb, 1636 Mail Servu'c Center,Raleigh,NC 27699-1636 FOR WATER SUPPLY WELLS ONLY: blot,/ 24c.For Water Supply&Injection wells: 13a.Yield(gpm) � ` Method of test: jj� Also submit one copy of this form within 30 days of completion:of • V1 11 Amount. -7� / well construction to the county health department of the county where ` 13b.Disinfection type: IA' // constructed Form CrW-1 North Carolina Department of Environment and Natural Resources-Division ofWater Resources Revised Atlpust20I3 • I