GW1--05906_Well Construction - GW1_20230918

WEIaIa CONSTRUCTION I2I;CORI) -- .
This fonu can br,used for single or multiple wells _ For lutennjl Use ONLY: "^
1.Well Contractor Information:
Dean Cook --�,_-- —� ! _..-..____.____._.____
Mitchell s'•;14;1-pre iz NES^ -� _ _.._..._
well Contractor 31i
)//��,,11 nh's^^clor Nnror, ••"o"" +'""----'-----_---.-.._.____.
NC Well Contractor Certification ft ft i ___-----
tint Number ,
ig.:(1 T1.R;�G 11_577`IFr`.i{giiii'i•'iRi-•e3scif). ''(.j ig
Dennis f�allanci Well - wells i :IvIN�i�if,+e'i+�li�n]c)lr:�F�.�. .+�.;
_ IrROM DIAMF•TER Drilling, Inc �'r°�- '�t-
- _ THICP. KNESS L
ATERIAL
Company Name
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2.Well Construction Permit H: C),23 p FROM _ DIAMETER �`
wedz .3 �:_-;r::;rd:..;...
-•---•------••--��..-_.__._-_„__,�_••_^_• THICKNESS MATERIAL
List all applicable well permits(i.e.CounT._._.^ ,, '•-'-••--.- -.____..____..__ ._... ft. .I in.f t.
ry.•S'rmc, r/nrinurr..Ajerrtat.erc.J
3.Well Use(check well use): fr. n ;,I
,_� ... ,
W'aterSttPPly 11 ---- __-�. t177.?":.S(aRFFN,7:_ - -- 1.77,7-- _
FROM YO_. •c ;.:+::,': ......... : ? i..v.+...:,».._.:t:.:'. :AT 1~'
t°Agricultural _„---_-, DIAM F'fF_R !SLOT SIL EE_ 'RIICKN ESS F1ATF)RIA I.<.:...
h7Municipal/f'ublic rt• rt• in: ' •
f_7G(othcrmal(IicatinpJCoolin r Supply) ' `_"- - j
b I P Y) °Residential Water Supply(single) w ft. in, ._ _______,
fr.
❑Industrial/Connerci(Il (t3.12 s dential'Water Supply _. : e-- " , ';;:.' �- -
I P Y(shirred) -18,i-G{ROI1.T __... :,�%• •_-.:-,::�.-
fllrri+ ) -
...._...._lx(fI1011 F'ROhl .TO.. _ ' _..2';i!'i.;;{� c�t9iy�":•
____. MATERIALS FMPLACF.MENTMETIIOR&AMO1in1''
Nnn-Water Supply Well: "__.___ _..___,.- ft. -
V f L cw�.. x
C7Monilou9ng 3 rr. (t•
----__._ ccovery -
injection Well: .••'-�`�'�-•---
J
(.7Aquifer Recharge ft.
l 7Groundwater Remediation �;ir9.:::SA'-ND%CI '•::-:•<::
• C1Aruifrr i•A.1!$�IiPAG1C�if.__e@p(tcs,�,hle� •:;:�a�; "'._.{ .:�•��,'� ;';<�_.
I Storage and Recovery °Salinity 13arrier - FROM .TO.TO MATERIAL, r,EMPLACEAENTMET'F10D�'
DAquifer Test !r. fr. �
CIStormwaterDrainage -.__-_.__T__.-_-.___-__
:xperimental'l'echnology C°SubsidenceCorittol (t ft.
_l
L] ru(tt e nal(Closed20•'ll 0.111."-- y
Loop) RItiI:ilYfvii ('atfa'i ti�(i lif liunel?hti'e la'f(:.1'I'r(tcc:r ..� _( ftuece:4seryj;%t`:11.1:"'''-FT;;- ; :
f7GeothermaI eatin.g/CoolinpReturn) °Other xplain(lder#21 Remarks) llFSCRIPTIUNjeolor�henlo oiUrockl gpraineise�ctc
4.Date Well(s)Completed:•
ft. ft. •
P �9-l��vlVr.IIIPH /, .d fr. ft. -_� �___.
Sa.Well Location: - - _ _ ____.._..___i_ e..T
j/ r�. tY^ 4• .,_. �-ir I r{'
OQJG h yr ._.__ -. t`-_.-_-._._ _'.._ ! L �.. bT ----
Facility/Owner Name -.-_ _
__.,.
' ft. ft. 1• q '
Facilitynu(ifapplicable) _.-_..___...._...- __..__.._..__.___.__.__;-_-----,-SEP._1._8...2oh1__._.__.
L e /, rt. ft.
Physical Ad.. s,City,and ,'.IL U0 �3 p >,s, Qi7 zG,.r/4_,_ a -ft. _... f'_ _... ._._.._._.-...I.i,_ ?.111Prrn-` O: c -13t ---'
•
County
- -—___._.__..___....__�____----._.___.V-_.____ �__.._.__
Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/minutes/seconds or dcc imal degrees: ..__.,_____ __ _.____-�_..___.._..._._.__.._._
(if well field,one let/long is sufficient) 22.certification:
• 3�� fr
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Signature ofOmiftcd Well Cootrnctor Date
6.Is(are)the well(s): , crmauent of
[Yl'cmporary
By signing this form,I hereby cent fy dine the well(s)was(were)constructed in accordance
with i.SA NCAC 02C.0/00 a•-1.5A NCAC 02C.0200 Well Construction•S•anda•r/.s and that t --
7,Is this a repair to an existing 1 well: OYes or ernro
copy of This record has been provided to the welt owner.
If rills is a repair,fill out known well construction information and explain the nature of the
repair rider1121 remarks section or on die hock of this form. 23.Site diagram or ndditihnal well details:
You may use,tha back Of this page to pritvide additional well site details or well
8.Number of wells constructed: 1 __ __ _ cunshu(aion details. You may also auach'adllitionat pages if necessary.
For multiple infection nr non-water supply wells ONLY with the it,you can
submit one form. .._. 1:IY•A1,,INS'Ia1.... NS
9.Total well depth below latiil surface: I or r _ ___ _ (ft,) 24n •ftor_,All Wells: Submit this for within :10 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2®100') construction to the following:
I.
10.Static water level below top of casing: �� ) Division of Witter Resources I ldforntation Processing Unit,
g' -_.. -_- (ft.
ill alerlevel is above casing„use"•r" '--�"' 1617 Meil$ervicr.Center,�RaleiRh,NC 27699-1617
]1.Borehole diameter;_,6"._______ (in.) 24b, Far injection Wells ONLY: In addition to sending the form to the address in
Rotary con above,construction
also-submit the Inuit n copy of this frirn within 30 days of completion of well
12.Well construction method: _ __._ ^^ eunSlnRaiot lu Iha following:
(i.e.linger;rotary,cable,direct push,etc.)
-- --_.
__ Division of Water Resources,Uurlergrounrl Injection Control Program,
FOR WATER SUPPLY WELLS Ol' i,Y: �- �� - ^.T___._ ^_- 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm)_-. Ord_ Air lift 24e.For Water,Supply&Injection Wells: i
.-_____-.-_ Method of lest:---.._........._.._.__.......__...__ i
H & hi Also submit one copy of this fonu whirrs 30 days of completion of
13b.Disinfection type:__._� Amount: CZ• well construction to the county health department of the county where
-.-- :._._._._ constructed. i
i
Font OW-I Notth Carolina Denn,tme.n,nrlinvirnn,nmil a„i Na+„ra,uar,.,,r,•,.r. h;,,;,;n....rsv.,,.,.u.,....,.,.... 1 �r„

f/�haOC 11 , /
of ra
1 h+1n(c•n County
�-i NEW WELL CONSTRUCTION
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PRIVATE DRINKING WATER WELL
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ARICIATITIRRE Ri , an'D?b a k„ I OG# 1130923-P •--"1 J ,,
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INT DED,U Shared Well ReSidenbal ; PID ## bS9ti.JE,,,!'_I ACIIrtiliE TEA
LOCATION Leatimmin Gap Road zo C ght cc'auec Prowry . _..__. _. —
D1.R,ECTIONS •.Lfiat^IF?ron Iron Rour-I in Right r.in�:1N21a 15. ..Pive ___.-.. r-._
pan*:Co diilans .
Well shaft be.constructal it compliance with:4•ii NC At.2C Rtal> .
Maintain minimum 5671xicks as applicable,able,ircludinrj 100'from ag mptir'S,.. ,LYn Cosa pants.
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This permit is valid for a period of five years i f.eri tear it:sive h_n_e*.ti Fit..��Timm it zi cu je errn act!:hat'Meru haL, ,-:r,n-at.^riz!Cariye In e7e z•^r
cL-a_Lre„anus wu{„:a.i w ii h ehr perrntt's i ?(1, It+rrt!Fcn•�:iam,Irg-dl"+Utr Z�.i�.-r.Fcca n rr.u.S1 TIION [m4 fo?-1uU ri sa..,AC II hr rr-4ic`el.!dre:c:urprcr,�G f h1C6'I Uk.=c..•
:au:ilL;i�eallhber..IC€I:K put into u.e. rt'rInrahrr.s3 th_ic*II twins.-,'h'MI-1%II I .u;srevI r.,fr.l :tin tl-oti JJ ut•r•^r.IIr.rs,e,coAtaloiN76Y' anM''MimI RV.'3I y.idj r,ro
qu raliteoi ar my:um ty,m2Prl.
A WELLHEAD coMpLETItord T1Ft;PEC'_TION MUST t1E APPROVED l3H)Rt FINAL POWER iS GRANTED OAR-The WELL IS PLACED ES.i O
SERVICE, PLEASE SCI1F_}UI,i=A'WELLI•lEAD TN 1:r1'orJ Al-tt i.z PUMP IrJsI cL A,TION. QU?E5TIQNS?[phone]
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Issue Dale; I:d12,fl2. jorr'o?han Fru€s,?Er�S 3 '9?y _ ,.. a'>titS,44. _._ fattioriz JState All/t