GW1--03621_Well Construction - GW1_20230526

i
Mint Form
WELL CONSTRUCTION RECORD(GW-11 -For Internal Use Only:
1.Well Contractor Informaatition;
.AT R. NE
FROM TO ES DCRD'TiON
FROM
well Contractor Name $' ft.
y5 ys'A rt. ft• ' j
1'3,•. . C ior•in lease wbUs OR R'ltii cable
NC Well Contractor Cortifloetioo Number FROM TO DIAMETER TRICin(Fa8 MATERIAr
ft. y p ft. 5 in, I ._
e C ' I1Vtsi - edt. srmaU lad-loo
Company
Q �I 3 FROM TO DLth>ETER TRIC[OVE99 MATERIAL
2.Well Construction Permit#:�J JA/2-3 t�(� ft, ft.
List all applicable well construction permits(La.UIC,County,State,Variance,e(o.J ft. ft.
3,Well Use(check well use): t N
Water Supply Well: FROM TO DIAMETER 8LOT91ZE nQctINEaB MATERIAL.
LAgflcultural �MunicipaUP6blic
emtal(IieatinglCooWg Suhply) WR@sidential Water Supply(single) inriaUCommeraial [3Residendal Water Supply(shared) is..'. . TTO TFRIALion (� ft. Q ft, �yt, i rC. !Jaon- ater Supply Well: ft ft.
Monitoring Rcoovory
Injec on Weil: ft, ft.
Aquifer Recharge ®Groundwater Remediatlon
•19,8AT(A/G ' YEL FA ll` ra It a le• EIIfPLACEMEtIT METHOD
Aquifer Storage and Recovery` ,` oSalinity Barrier FROM (t, To ft. MATERIAL
Aquifer Test ; ,>� [)StormwaterDrainage
.��I•' E3Subsidence Control tt' ft.
LgabeExperimental Technology �.. :i.�
(isothermal(Closed Loop) Tracer FROM L-TOO. �dtrDESCRD'Tioe Ncolor hardness solllroek We,OLD Din etc.
Geothermal(Heating/Cooling(Heating/Cooling Retum Other(explain under#21 Remarks O ft. q
4.Date Well(s)Completed:,5�— il_/J,3_ Well TD#. tt' H' trGtn f fi'G
% fa
So.Well Location: B,
Facility/Owner Name
FaolUty ID11(if applicable)
nn ft
30 v 4— ri e4 ft.
X&A;�
Cl nd Zi 2li _.._,
County Parcol ldantfficatiou No.(PIN)-
Sb.Latitude and longitude In degrees/minutes/secont(s or decimal degrees: jCcaflon,(if well sold,one latllong Is sutfiolant)
NCertified WeU o eato Date
6.Is(ore)the well(s)IRPermonent or �Temporery: hi
BY signing this form 1 hereby cerr(fy that the well(q)+vas(�vereJ eonsrrucred/n accordance
7.Is this a repair to an existing well: [3Yes or §1No with 13A NCAC 02C.0100 or ISA NCAC 02C.0200 We
ll Construction Srandords and that a
copy ojthls record has b
Ijthts Is a repair,Jill out/mown well construction hifortnallon and explain the nature oj(he been provided to the well owner.
•rdpalr under 021 remarks aeciton or on the back of th(s fora+. 23,Site diagram or additional well details:
You may use the back of this page to provide additional wall ells details or wall
8.For Geoprobe/DPT or Closed-hoop;Geoth-ormal Wells having the same construction details. You may also attach additional pages If necessary.
construction,only 1 GW-1 is needed,'hi�leato TOTAL NUMBBR of wells drilled: Qrrn,��••+-�Ar••nuGTRirC1'IONS l
-�- —
ce: (ft-) 24a.' For Ail Wells: Submit this form within-,30 days of completion of well
9,Total well depth below land surfa
For multlplo wells Its all depths(fd(JjerenI(exarpple=3 ce DO"and 2®1001 construction to the following:
ft. Division of Water Resources,Information Processing Unit,
10,Static water level below top of casing: (ft.),
) 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above easing use"+"
I1,Borehole dlami is r: .YL—.--(�•) 24b.For LniecHon Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction mothodi (9 Y y construction to the followlIng:
(i.e•sugar,rotary,cable,direct push.etc,) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Map Service Center,Raleigh,NC 27699.1636
r 24a]S '�` Suanly&s 1niection Wells: In addition to sending the form to
13a,Yield(gpin). Method of test: the addresses) above, also submit one copy of this form within 30 days of
VL Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
North Carolina Department of Bovirommatel Quality-Division of water Resourece
Revised 2.22-2016
Form OW-1
\n .n. vi-�t R ll Uq
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