GW1--03740_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
i.Well Contractor Information: —
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Well Conh'actorNaino 14 ft -
N C i J C_ ft, rt,
NNC Well Contractor CertlRcationNumb-erg 3covmnlrt. s:>y M •f°I!±mrD1AMETERen's`DTR NCN1ESSfiA i11MATERIAL
lJI ye.r �';�LrQ �� 1��� '/�R o ft. To ft, _ In,
Company Name 1 6ifb'r.;iNNDR'6aS tO1;.tii7111NGf eofhormnl.ei sod+Ibo
/�,I FROM TO DLIMETE TIIICKNF.SS MATERIAL
2.Well Construction Permit#:, 1•
List all applicable bell construcflon perndls Q,e,UIC,County,Stale,Variance,etc,)
ft. ft,
3,Well Use(check well use): f -.• . . _
WatcrSupplyWell; Fit TO DIAMETER SLOTSIZE T}I CI RSS _h_I ff:IIIAL
r
r1ndwIriallCommercial
ricultilral Municipal/Public L.•• in, ;' j
othertnol(Heatillg/CoolIng Supply) Residential Water Supply(single) .f(, ft,usidential Water Supply(shared) FROM TO MATERIALEMPLACEA EN'fMEiIIOUR�AMOUi anon V/r, ft, ft, le_ t" �1
Non-Water Supply We111�;, .,-'�• '
Monitoring c ecovery ft, ft,
InJectlo11 Well: ft,
A uiferRechar a 0ftahrdwaterRomediation
q g _ pr^,,,.r it;•t9r:Sil'ND/,G '`.YEliiEACIC:af• f IlenUlo
Aquifer Storageal�chti-etb+itry`':,x �r� USalinityBarrier FROM TO MATERIAL EMPLACEMF.N'rh1L+'I'non
Aquifer Test � Ei Storinwater Drainage Zb ft. 7 re —
ft, ft.Experimental Technology []Subsidence Control
i 'Geothennal(Closed Loop) Tracer `t"r M T -.•C3;nttholi''rdddlfRIPTIslN col f noeoesnr
FROM TO DESCRIPTION color hmvinosr so Urack Ipm Rrnlq size,elc�—
Other(explain under#21 Remarks
Geothermal(Heating/Coolin Return) � ft, � ft,
4.Dnte Well(s)Completed: r Z 3 Well ID# fL -la —
ft. ft.
Sa,1Ye11 I,ocnllon: ft, ft.LIS
� fL ft.
Pacill 4ID#(ifaPplicable) � .�^ •`�•� S—f- _- {''w,a
ft. ft:
S tN1�i 2 I1c•F c A'. ►s G�tiP. l - ft, ft. - ---
Physical Address,City,and Zip L.`7 210�)
to ��ni. ,.; �•.: ..�:.•.. + '
IV
Par cat Identification No,(PIN)
County
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,0110 IeUlong is sufficient) 22,Cortiflefloo I
S.�.3 1 CI, 7 2 q:S_2 6Z_W
6.Is(arc)the wells)icrmnnent or oTempornry
Signature Co Red Wo-11CONtractor Dnla
By slgnh this form,1 hereby cart{fy that lire+rell(,rJ"'as(iraraJ conxh•ucterl In rrcc•wrdmree
7,Is this a repair to an existing well: yes or :` o lrltlr 15A CAC 02C.0100 or1SANCAC 02C.0200 Well Construction Standards will drat a
lfllas Is a repair,fill out known bell construction hUor•mation and explain ilia nature of the copy of this record has bean provided to the trot/wrrnar,
repair under#21 raruarkssecllonoroil the backofddsfornr' 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed, Indieato TOTAL NUMBER of wells
drilled: §UUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (ft,) 24a, For All Wells: Submit this form within 30 days of completion of well
Ror rrrrrillple wells list all depths lfdWarenf(example.3Q200'and 2ur 100') construction to the following:
10.Stalle water level below top of casing: 1 1S (ft.) Division of Water Resources.Informnllon 1'rocesslug Unll,
Iflvaler IeWl is above casing,use"�" � 1617 Mail Service Center,Raleigh,IVC 27G99-1(17 11,Borehole diameter: % (In,) 24b,Ear Tnlectlon Wei: In addition to sending the form to the address in 24a
h above,also submit one copy of this form within 30 days of completion of well
12,ell construction method: �' construction.to the following:
(I.e.,augur,rotary,cable,direct pasty etc,)
Division of Water Resourcesl,Undm•grouud]nJcclloli Conhrol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Setvlcc!Cenlcr,Raleigh,NC 29699-I636
/� G1,d 24c,To Water Sunniv &Inieetlon ells) In lddition to sending the form
13n,Yield(gpm) °� ' to
" ' G IMethod of fest:
the address(es) above, also submit one copy of this form within 30 days of
Amount:
r' _
completion of well construction)to the county health department of the county
13b.Disinfection type:
where constructed.
Porn OW-1 Nortlt Carolina Deparhnent of Environmental Quality-Division of Water Resouroos
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