GW1--07219_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD For Internal Use ONLY: .'1
% Ms form can be unarm single is multiple wells
1.Well Contractor Information: •
14.WATER ZONES . I i
• r- al . �!✓_S 1 lk FROM TO DESCRIPTION
Well ContraemrNrtnrae 80 e% Ift Sr`1 W i�/Aka S f 1 .
t&(C iJJ C' aSS-5--f- t
NCWcltConructorCes:ificatL0uNumbec le• TER:CAs tthritiaSkaaeawensfr0$LINER Ofap 6k)
Molts TO DIAMETER THICKNESS DATERIAI4
A-114k 2 fr FI-nl \a l(t_Lt_ $e4.1 bt2.(d• CY ft. 9c ft .947 ' IA , Sc-k ifC) PV'c_ .
Company Name ' fu.mittasitmoR G(sCutt{et II EI SeIH D) •
Aug- FROM TO DIAMETER is•
TRIMS n MATERIAL
2 Well Coneiruetlon Permit 11: r , �ir(i,
Lill all applicable well partials(l.e.Cooly,3(oie,Variance,6aecilam,eta) i pa
I, ,
• 3.Well Use(check well use): i7, • 1 •
tWater Vdk (:smoae�TO 1 DMMETFR { 51.OTain (THICHNF 5 lttlt'E7t'RtAL '
oAgricuitural oMunicipal/Public .t5014 43.0 ft. .2 fill . 0/a SBA i'4'Q PVC.
t2Oetrt seine)(EIeatingCoolinn Supply) CIResidential Water Supply(single) 28,trlil�)17 ft irm j e '
Cllnduattia1/Commercial ❑Residential WaterSuMply(shared) PROM To . srnrt$rtttei. ' smrs,ocamioci�n�tsruonaAniotircr
rrigation o f ' as t "IIK,';,. Pocj t2.telb
Non-Water Supply Wdh & ft.
Monitoring._ l3Racovery . - _ -_--
Injection Wei lt
•
ClAquifer Recharge CIGroundwater Rentediation ••19'SANDlCIAVEL PACKt u1Opttta '
O niter Storage and Recovery tlSalinitp Barrier •1 PROM 10 MATMIAL E PLAt3aatlENYM67i10D
t
A9 n. . /red r. AI G-2/211/FL. PaUCt b
OAquifer Test OStoemwata Drainage ft. • ft.
GilicperiRtetrtelTechnology GlSubsidenccOontml 20:'DRILI,OIQ LOC(*Sad ediationdebteitiftereetesol •
DOeothermul(Closed Loop) DTracer FROM TO _ DESCRIPTION(toter,budoeu,seWrook[Yee.psiss3 t,eta)
t t7deothermal(Neating/Cooling Return) 170thersexplain under ill Remarks) 0 Rt a. at• -rye ' To,`C
a 1 o it -7194 1 C,Lit-y
4.Date Will(e)Completed;%G/i7/a, Well IDII 0 ft. p ft. TA-i ;SA•dd 6/f't APy
5a.Weil Location: ao IL 30 ft. 6t4,i, S A•11 b/C 4y
bout s41._45 G4A-PPa~.14:- 30 f 7o 1 GI&Y wiyI S Ft'E,L.c..
Feuifity/OwaeiNeme Facility iDM(if applicable) -7O 9O 54,-Lis / gK•E.1t
5 Vic, w u[-r¢ I-1 a--; ecl 44.41 r✓a4(l\ •
t 79 SPY 10 ft /oo it 54,4 /Cq,r /• r.i.k� �-1
Phyelnal Address,City,and Zip • SL RL'MAR123 ".•.wk..e :. ii s;: 9 {_..1
PE.2o[t,tvt{4•a s �'r 202�
County Parcel Identification No.(PIN)
Sb.Latitude end Longitude in degreerWminuttee/seconds or de dmal degreest 22.Certiflcadon: t n° ^ ?'' " .'^ 1'€:'? ,
(tfwelt field,one tat/long is sufficient) D:e i;• .'0c1
3(p. I SS 4L N - fro:3�7 5 7 w �..k.i. _LL ._ • /0 7/
SignatureofCcrtiflcd Well Contractor j Date
ti.is(are)the wdl(s):.r,l ermenant or []Temporary By stgrtlew this farm,I hereby nett&that the milts)war twos)constructed in aceordmxe
with ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Constr,tetlon Standards and theta
7.1a Ibis repair to an existing well: OYes or gin copy of this record Imo been provided to the well owner. .__ _
-Phis isii4:ir :/Ii1oatlur`owri wolloinstruclie inflowaJon raid axplabtdre native Ohs •
23.Site diagram or additional well dltiHl9:
reparrpwdsrtlJJ muarl�mtlan oral the bxkofthtsl6sn You may use the back of this page to provide additional well site details or weU
• 8.Number of wells constructed: • construction details, You may also attach additional pages if necessary.
For inuhiplel,t/ectlonornou.ivatar supply walls ONLY withthesautectatrnettan,youcan SURMIITALIlVS1[JL'YIQN9 I,
submit owe form. •
4.Total well depth below land surface. /Oct (it.) Zia.For All Wan: Submit this from within 30 days of completion of well
For multiple welts list all deptfcr lfd(BEn t(ample-3@200'and VIM oonstlitetion to the Mowing: 1•
10.Static water level below top of easing: /a I (ft) Division of Water Resources,Information Processing Unit,
'Water level is above mains,,use"+" 1617 Mail Service Center,Raleigh,NC 276991617
:t
IL Borehole diameter. (in.) . • 24h For Wanton Wtlolltl ONLY! In addition to seeing the form to the address
24a above,also submit a copy of this form within 30 days of completion of t
12.Well construction method: ili,LV b 1?-o-r R"e4 construction to the Mowing:
I.C.( auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground lnjeetion Central Program,
. FOR WATER SUPPLY WELLS ONLY. • 1636 Mail Service Center,Raleigh,NC 21699-1636
13a.Yield(gain) at".) Method of teat; G ! v" '� 24C.For Water Slimily&Inaction ells
C A to err. i-fy cKC s+�i� Also submit ono copy of this foim'i within 30 days of completion of
131,.Disinfection type:� E. Amount 62 0 Z.. - well commotion to the county health department of the county where
Forth GW.1 North Carolina Depadmentof Environment and Natural Resources-Divlalon of Water Resources Revised August 201:
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