GW1--06306_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY; •
This form can be used for single or multiple wells
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1.Well Contractor Information: 14 tY4A I ER ZOh)LS G,
a FROM ,TO } DESCRIPTION
P itli Pobk
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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
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2.Well Construction Permit#: l'� FROM ft.
5 TO i f DIAMETER THICKNESS MATERIAL
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'in •
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Liu all applicable well permits(i.e.County,State,-Variance,Injection eta:) ft
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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 : _. .
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Fa ty/Owner Name Facility TM(if applicable) ft fL ' , -✓'
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`155$ ,I4gig S/14ay all L_IukC `r ft. -6�� t0?4
Physical. dress.Ci and Zi d:xt:SEnt1BKS .,
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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
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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
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