GW1--06748_Well Construction - GW1_20231023

•
wru,CONSTRUCTIO CORD For Intend UseONLY:
This form on be used for single ormnttiple wells I '
1.Well Contractor Information:
soh pee 1 TO —DESC�1PHON
Wee Contrer:Wedame /DO ft. a 9 T ln►
.
NC Well Conhector on N` 4 IS.ODTER'CA61N6{tbi'jauttl �reDkOlLGR Rfif m
Q MOM TO D ITICIInE S SIATIuiAL '
f a dPoàTv ale l * twvj cot ' ? ` P vc
Comps r Name y '1b.1NNBRC'�IS NG OR'Igt161N a n1
W tiff 0 • V'��-3 FROM TO DIAL 18[TRIMNESSMX7�A7.
g.Well Construction Permit 6 V(: I ft P m.
List all applicable well penniu(Le Coratty.SYme,Variance,Infect on.era)
ft. it: te •
3.Well Use(cheek well use): • . .17:SCRSEN:. .. '- - ' •
Water Supply Well: FROM To - Diana - StOTs1ZE ,T4acarv8Ss MATT anti.
•
I CDAgricultural DJ4u icipal/Public fu ft is
•
C)Gcothetn:el(I3eating/Cooling Supply) j'Residential Water Supply(single)
ft. ft. in.
DlndustriaUConmercial °Residential Water Supply(shared) : :12I + ` . ' . . _ •FROM TO MATERIAL EMPLACEMENT ..� : t,hAM•
OUNT
Non-Water tamer Supply Well: d 10 h' p-i1 K Q ra u a .
ft. ft.
V
°Monitoring °Recovsy
. 1q(ecflon Wells . ft. f
CDAgnifer Recharge °Groundwater Remediation 9.. YL1.PAcis{irrime wornei= -. - . -. .. ,
• PROM To E MATOttAL 81upLAf lFNTMETROD
['Aquifer Storage and Recovery °Salinity Ranier ft. et, t
CiAquiter'i'est MStormwater Drainage • .
ft. ffI !
°Experimental Technology C1Subsideace Control •
2%.1/111°Geothemmal(Closed Loop) °Tracer { DESCRIPTION Stator goats: eta
Clt3erotttatntel(ReawtB/CooltngRcturn) °o@ter(explain under 4i2I Remarks) 0 R' 50 it G'a
a ted:Qisle a We11IDS 5-0 ft. 62o iw sin.*o rock
+b.Date Well(s)C .�+ ,:�,tw . j` ..
Sa Well Location: ft.1 R T_
1 at eft Kifirimp,1461n it ft -°" -i` ' ''
. Pacility/OwnerName Facility1D#(if applicable) iw OCT 9 2(12
(0caI /Were 11taw t Rot , 2.1(o(9
PhyaicalAddress.CitY,sad?le 21 • . .:G`'.. ...'..T.;.' •.,..::: 11:'d
bilii<e•
C, r, Parcel identification No.(P1N)
1 •
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: . 22.certification:
(ifwelt field,oneiatRong is su oicnt)
N w ( -' _-
Sl. ofCertillad Welt contractor ; Date
6.Is(are)the well(s): 111Permanent or °Temporary By aping this form.1 hereby cer*that the well(s)was(were)constructed to aceonlance
with 15A NCAC O2C.0100 or 15A NCAC 02C.0200 Well Constrtaton Standar&anti that a
7.Is this a repair to an existing well: OYes or lik ropy of ihis mold has been prodded to the well owner.
!'this It repair,fill out known well construction li bun attonandespla►n the nantre of the!. .Byte diagram or additional well details:�.--..ft— a it7 ��.n:L�.. If'"'lariat 1XLa hncF.affitt fir„
__- — :.:.._ You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: ' construction details. You may also attach additional pages ifnecessary.
For melapie infection or on.watersupplywells ONLY with the same conshwedon.youcao
adb nofag/W a SnRAl.Aik .l'1 rAL INS'TU1CFIOP '
9.Total well depth below land surface: � crw (ft.) 24a.For Ail,Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdill'ereru(ample-3Qa 200'aand 2 a®100') consbuction to the following: 1
tO.Static water level belowd�
top of casing: t, (it) Division of Water Resources,Information Processing Unit,
If water level is above carom use"+I 1617 Mail Service Center,Raleigh,NC 27699.1617
1I.Borehole diameter:, P lial 4` :*r.=--`..r--pelt<er..ert1WIr V. rm...ra_ en r.. ,arxA.s.m�...r,e_,F..e.ra>�_^
� 24a above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: air rep-me consttuction to the following:
(A Sig.:,iiita+j,Lito�i ¢cia4ytwy cis..)
Divilliou of Watts Resources,Underground lujecdon Cooked'Program,
FOR WATER SUPPL WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 1 Method of testb l o 24c.For Water Small&Median Wells:
1 Also submit one copy of this fbim within 30 days of completion of
f
131.Disinfection type: h'C 1A. Amount: •'7 I bS . . well construction to the county health department of the county where
constructed.
Form GWl North Carolina Department of Environment and Natmai Resources—Division of Water to ourees Revised August 2013