HomeMy WebLinkAboutGW1--05896_Well Construction - GW1_20230918 ` Print form
WELL CONSTRUCTION RECORD(CW-U For Internal Use Only:
1.Well Co.tractor Iafor atioa:
J JO h Irl BO\i t l y 1 - I ItI14.WATT* TO _# ----
mat
lammenearar Name 'sr i R. li
2505 'sr
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NC well Contractor Certification Nwnb�r IS.tw7Rk C.� c .dn-enrol wait at LIN=(If 1
l a l e .F Sp OIL.)
r/ rtt<wrn _— DUMkrFat . Rrncwcss TatwY Vi c, n. n. an.
Company ansr (� li,INNER CASING OR T11RINf:J (ZtalMer_mal doed•lOafi)
2.Well Cnaetruetinn Permit#: room n► wwMFTVJ1 T111CKNM MATRRIA I.
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List all i y.6usble well rnwsrvrennis pennies ll e.(JIC.Comity,17Mr.Ptariaoce,e*-.f 4-\.5 IL & R s 2 e3Io. r ' 86 ga I.1.
3.Well Use(check well ace):
17.9CRRF.N ---------� - __-
Watet Supply Wen: MOM Trot) DIAMt rT1t airrsnpt TAae7t7K� �ata,nae..
t�sriaufltrtal []Mtmirjpal/Pubhc n_ n, is
southeemsl(tleatin.siCooling Supply) Residential Water Supply(single) q n —
[ItdusuiaVCwxrtttiaeialResidential Water Supply(sharexl) t
e.
it GROUr
Irrigation s1N1MN 7(7�1 LM-AT_! iAI. +_ p4LAC7 F_Mf Mf'R!OD&AMOIIKT
lion-Water Supply Well: O n f'-4ro (Xi`A-Cf�t-}4____-_iJ c
MonilonngRecovery n. R
Injection Well: n it
- -,
Aquifer Recharge []Grotmdwatcr Rcrrtaliation 19.SAND/GRAVEL PACK(if applicable?
Aquifer Storage and Recovery []Salinity Barrier IMOM ro +,Tt tlAi, — FJNnacEVIENT Menton
Aquifer Test []Stonnwater Drainage ft. ft.
Experimental Technology []Subsidence Control — — ►t• ft. --
(iootherttml(Closed Loop) []Tracer 20.DRILLING I.00(attach additional sheets if ne ceasaey)
Fltoaf To DF_scn�f TI°nester.berd.ss,seivrotic tyre.gala Age.eery
Geothermal
(Heating/Cooling Return) [](TUter(ez lain under N21 Remarks) � rt. Zl ft. �I i
rZap /-
4.Date Well(s)Colnpletcd: SC((� / Well 1D# ft_ L/n- V ! (7-
Se�Wee!Lama= (-),
a_ R
��C.r y)r (t� r j/t f fni/I/eV R. R ----- k s- l� VI
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Pare ty/!honer Name 1 (/acility IDS(if applicable) ---fe -- fC t I.ti, ,+,.,�i i `
r� 4� G r� �' � — ----" ------------ SEP 1 8 ?023
P,,,,�; ywd,�.City.„,d . y ft.
21_REMARKS
County Parcel Identification No.(PiN) ''"'
Sta.Latitude and lougitode in degrees/minutes/seconds or decimal degrees:
(ifwell field.iioc lat/ka,g is sufficient) 22.Certification: r
V
6.la(are)the wett(s)ipPermanent or []7•emporary -) 7 5/2-"3
Signature off ifi sd Well Contractor Dam
By signing this on.,.I hereby certify that the w (s was(sere)constructed in accordance
7.is this a repair to an existing well: []Yes or�No with 15A N 02C.0100or ISANC:4C 02C.I) Well Construction Standards and that a
If this is a ri.pair,fill out known will construrrwn information explain the nature of the cop'of this record has been provided ro the well c wsur
repair under 02.1 remarks section or on the back of this form.
23.Site diagram or additional well det eibi:
8.For Genprobe/DPT nr Closed-Loop Geothermal Wells having the same you may use the back of this page to provide additional well site details or well
construction,only 1 (1W-1 is needed. indicate TOTAL yUMBER of wells construction details. You may also attach additional pages i f necessary.
drilled: _ I —__--- , f_/ ( SUBMITTAL INSTRUCf7ONS
9.Total well depth below land surface: (4'N/ (11-) 24a. For All Wells: Submit this form within 30 days ofcompletion of well
For multiple wells list all depths if de erenl(crumple-3(gi200'and?way) -ti ) mp
construcon to the following:
till.Static water level below tap of using: 23 (ft-) Division of Water Resources,Information Prscessittg Unit,
11 muter beet a ais.w r/nurg use
3 1617 Mail Service Center.1v{eiglt,NC 27699-1617
11.Borehole diameter: (in.) 24b_ For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days ofcompletion of well
12.Well construction method: Y ��r construction to the following:
(i.e.aicr,rotary,cable e(neci push.etc)
Division of Water Resources,Underground injection Control Program.
FOR WATER SUPPLY WWRL S ONLY: 1 1636 Mai Service Center,Raleigh,NC 27699-1636
13a.Yield Wiwi_____5.--D --- Method of test: 1 Q tAJ 24c- For Wafer Supply&Injection Wells: In addition to sending the form to
j the address(es) above, also submit one copy of this form within 30 days of
1I3b..Disinfection type___ �.,
-j}T T 1 Amount: ta
1 07 . completion of well construction to the coity health department of the alunly
where ductal.
I i:4tn Cs W.1 North Carolina Depantne:nt of Fnnrantoeaeai Quality-Division of Water Resources Revised 2-22-2016