GW1--06504_Well Construction - GW1_20231013

WELL C(aNSTRUCTION RECORD GW'1 rut��.. ..._.
1. ell Conti act r I nfor rrtati�' FROM
M ER ZOOS DESCRIP'n iv
FROr �
Well matt Name 71511 wells OR LINER ifa••litxbte
15. CASING tor tnuDIA TER THICKNESS
FROM
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NC Well Gontrac or Certification Number D R. ,
O 16.INNER WOMINIIIII ASING ORTUBI .eothermai closed-ttoo.
DIAMETER cKNEsS
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Company N�unc
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List all applicableUs ( heck construction pe SOT SIZE TRIG NESS
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3.Weil Use(check well use): /FRJO�M�'l��• �
Water 113023111111
uItU Well: 0M icipal1Public IL�l�.®�r�
li Agricultural esidential Water Supply(single)
Geothermal(HeatingfCooling Supply) 1 (shared) F�T EMPLACEMENT METHOD&AMOUNT
Ili MINIIII
'7Residendal Water Supply FROM� i��r,'�'�''
it lridustriaUCommercial ft. I,�
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Non-Water Supply Well: Recovery. ®�
j�;IylaFtitoCing e EMPLACEMENT METHOD
I rejection Well Groundwater Rernedfation 19.sANDiGR O PACK if a+•lit ahfe
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r auGts t / , �j�1t� �
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Parcel Identification No.(PIN)
ca;�.:y degrees:
re minute/secondsot decimal deg 22.Certifi - a /CP /� /���
1::A. e de and longitude sufficient))9S
ttila:ell held,one LstfdantiW
Date
� Signature of Certified Well Contractor was(were)constructed in occotrlan
are thewell(S) Ermanent oil- OTeriporaryeVellConstruction Standards and that
�.lei ) By signing this form,I hereby certify that the well(s)
with ISA NCAC 02C.0100 or provided NCAC to the C.200
7.1sIS Is a air. to anexisting well: �- or
0 copy of this retard has been
its section or on the hack o'jcjsfo 23.Ste diagr am or additional well details:
additional well site details or w
er.
E;MIS is a repair,faEi zr•:�rmown well eonstruerEt��r;sr'atfon and explain the nature of the You may use the back of this pageP if necessary.
Bre.xttr wGer pol Mreci g die same
8.For Geop
r S or Closed Lip G �'m�L NUMBERconstruction details' You may also attach additional pages
construction,�;tty I.GW-1 is needed. Indfcae TOTAL NUMBER of wells SUMO I TTAL l IV RIJCT{ONEdrilled (ft.) 24a, For All Wells: Submit this form within 30 days of completion of s
den land surface /�� construction n— to following: Unit,
F.Taal t^?t`.g>d'I,t r different(example-3' ,200'and 2'i)1001a e .r=�� :r cptg� ?rsif�l� Division of Water Resources,Information Processing(ft.)
Grp a text ins,M tap of casing: 1617 M all Service Center,Raleigh,NC 27699-1617
ID_ d , the form to the address in
3-1- °.ci��t�a ameterng, - 24b.For Injection Wells In addition to sending
(rn') above; also submit one copy of this fotTn'.vithfn 30 days of completion of
11.Bite 416atit2tt3: /)
` canstruetion to the following:
.^„ , i ,L^ -ems e, it ctpa:l: J Division of Water Resource,Underground Injection Control Progres
1636 fvi ail Service Otter,Raleigh,. NC 27699-1636
rPaiRugtnrsn_sc'�e-axe.direct P'.tsh,'eta)
lii�i��R�� -tea IpPI Y WELLSONL`!: 24c.For aternlectfon W�Is: oaddition this fortn within 3Ue fo
da
�gsd Of tom: t ekhtr� ) above, also submit one copy
?tro�tF1�;�tIfi'w�i(gpm) �-. completion of well construction to the county health department o, the c
de
art I
Amount t alit;� 5.4elY,t,a: eR dyre;
la,.1iTI�9SfPCtiQn'type: Revised 2-22-2e1