GW1--06315_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contactor))b3nrutaatttoon:/
/ern .4 . 1' Or/,1. t- 4 wnot mos 1 ! • '
FROM TO
Well Contractor Nano DESCRIPTION .-
a-(,9-3 rt. ft. 1
NC Well Connector Certification Number 1ii.OUI11ilk Ci¢i11ZN1 (far aattlt red tr ) l Of -
2,i •r it uifa1'l1 d1�U .2. ft. TO �. ��' ;,. _-�
Commerce Name
:12090at — ' Olt Alisteelik. :
Z.WellConstrnt;'ttota Pali i{: -PROM TO DIAM�r'BR. MATERIAL ''
List ail applicable nisi!oonstaucaon permits(r.e,UIC County,State,Variance,etc.) tL ft. la.
3.Well Use(check well true): IL ft.
Water Supply R►�: gT. . •. :
OM � DIAMETER'' SLOT I1IZ 'rlic '&e MATERIAL
❑Agric i ❑Municipal/Public ft. R in.;
❑Geotiemel(Heating/Cooling Supply) esidential Water Supply(single) rt. it. in.; '
❑Ina iai/Coinmetcial DfResidendal Water Supply(shared) a szamm 1
❑ttrigatiear ❑Wells>100,000 GPD FROM TO ' i►f TERMCr, EMPd.ACESTE Yr r 3OD sit AMOUNT
`
Non-Water Supply Wit: '
❑Motnito i>, ❑Reacovery ft. ft.
Nair en : - ft.
❑Aquifer Recharge ❑Groundwater Reanediation
❑Aquifer Storage and Recovery ❑Salinity Barrier. itM TO • _ MATIt1AL ! tiMPLACsME*rr METHOD' •',
0/Wafer Test ❑Stainmwatcr Drainage it: ft.
❑Expothneattal Technology DSubsid�ce Control -, ft. ft. �`~
❑G erinsl(ClosedLoop) • ❑Tracer 'a IdialiLriG VOG(.o,•-It slklltisaa€t sawn1fra to D
❑Geothcuuai(Hee�ti�rlg/Cooling Return ❑Other(explain-under#21 Remarks) FROM •O DESCRIPTION(taw,ice,loaned:true,ae 2 eke,ear.)
4-Datn,WalI(e)C:oo leted:•. ` '/, Wel Imo
fG It. tJ
Facility/Diener.Name` .Facility ID#(if applicable)
,'7/7.6 72S ►�3)14- J-uuc.4 4 `i f SEp 6 2UZ3
Physical;Addreu;k:rty.ed•2ip - • • ' 'ram•6-7r .'3 .)!:7
,in/J-iSp rm iL-4 .
ca'zmty -Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.rare lorleng ii soffeieni) 22.Certification:
/1443— N fe/e/e•g` W • .1 94-01,66e
6.Wore)the weli(e) arm anent or ❑Temporary
i we of Certified Well Contractor I' Date
By signing.Ms form.l heresy ee►*that the'well(s)rwav(ware)constructed in.z cardance with
7.Is this a repair to an ezladng well: ❑Yes or ,11t1Na 1 SA NCAC 02C.0100 or 1 SA NCAC 02C'.0200 Well Construction Smndards and that a copy
If this is a repair,flI out beaum'weii construction irl(ornation•asd explain the nature of the of ih r±eeeed her been p ovlded to the well owsaer. _
repair snider#21 rtasmla section or on the beck of Mb form.
23.Site diagram or ardi ows'well detain:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sane You may use the back of this page,to provide additional well construction info
construction,only -1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).Yon may also attach additional pages if neeeeeery.
drilled: , f 24.SUBMITTAL INSTRUCTIONS
9 !1 7 - . -
. mel Total well below landrent Lsurface: (R-) ,Submit,tttis GSA+-I witirnn 30 days of well completionper fire following:For nvltiple wells lisraU'dpatks�d((tsrsnt(aunnpicr-3(�200'and 1®1 u??. ; . 3' roP 2:
j y� 24a. For All Web: Originalform to Division of Water Resources
10.Static wets :level beglow top of teasing J t'J (Q�t,) )'i
(Jxastalu+sltra6ove;mr + anformetion-Processing Unit;'16171ISC,Raaleigh,MC-27699'1617' ' . .
4 1/ 24b:For`Iltleetion Wells:;Copy to.DWR;Uncle—U*6M d tgjeotion Control(WC)
11 diameter: l•'t' (ia) .
s
:'. -, ... .. lgram,•036:MSir,Raleigh,NC 27 699-1636 ,.... ... __ ._. ..
I2 Well atrtecalo>a'timofBod. P—� -- 24c.For_Water Suopty�it d Open-Loser ernraPRetarn`Wells:Copy`to'the
(i a t*4 merry.cOt,Is,dhaK push,etc.) health� county environmental department of the county where installed ,,,_,.._.,
FOR WATER SUPPLY WELLS ONLY:,_ . „ - . - . -_ _ . I
24d For Wtrlatr Welk' r®rlue3n�earn 1 ==a r C:PD:-Cngry to DWR;CePCUA`,
LLam" Passau Program,1611 MSC,Raleigh,NC 2 .99-1611
113..Ykdd Wm) V Metttod.of test: Ae,e_���Tr ;
13b.Diaaiafteetba type: Pipe— Amount: 4/Yt,�✓
i
Form Gill-1 North Cunha Department ofEnvironmental Quality-Division of-Water Recounts .haul .6•6-2018 '