HomeMy WebLinkAboutGW1--07220_Well Construction - GW1_20231108 i
WELL CONSJ'RUCTIONR CORD For Internal Use ONLY: I
s ThIsformwnbe used for single or multiple wells is .
1.Well Contractor Information: - I'
14.WATER ZONES . I I
P.G . W. -7
-- FROM TO MORMON
WelContn+ctorNome 50f1. !O 6 d. S4t44/Me.J sa .4._
alicWc355'a-A i
NC WeltContwetorCeiiftcafioaNumber ' ��ERCS O F nsidtveI OR LINER HIappfleaMe)
FROM TO DIAMETER THICKNESS MATERIAL •
04-114ERlca NI l....let i `'t Al t.tP o ° eia a a (, ' ter Sc k _, f'VC
Company Name ' 16.1NNERCA8IN6'OR UMW(t r
, tc les°
FROM TO DIAMETER III MATERIAL
2.Well Conatrucdon Pernik li: 'V/ti- ft, ' ft. //��(fJ �� is•
Lfst al appI/cab/a well perlxirs/f e.County,State,Vttrtmtce,Reganetc.J ° '�d!
3.Well Use(cheek well use): mamas • - . • •
'• IWrrtert3appt7Welk ( FROM TO 1 DIAMETER I SLOT ME I.TIHCKNRRS 1 MATERIAL
°AgriculNral °Mttnicipal/Public
,t o tr. coo ft• a tu° . o id. �C.t PVC
•
DOcutht rmat(Heating/CoolingOI✓Supply) esidrntw i
l Water Supply(sin0le) R' it mi❑industrial/Commercial °Residential Water Supply(shared) i steer To •• . arwssRSAs. ' snsrr,Acemmvrnsrruone,Ansourr
_ () ft. ''-ciIt' a focit t_b
Non-Water supply Weil: ft - ft.
°Monitoring °Recovery ft ft
Injection Wen; ,
°Aquifer Recharge . DCkoundwater Remediation ••19.SaNDJOHAVEL P (liairtitea►let •
mow { TO MATERIAL ' EMPIACEMRNTM=NOD
LlAquifer Storage and Recovery °Salitsity Battier 020 et, ,0 er. • 16r2ti-VfJ— Pocie_ta,
QAquithr Test °Stonnwater Drainage ft. ft.°Experimental TechnologyG1Subsidence Control
20MtILLfttiGiLt (athchadditional:duetitfneeme rsd •
❑t3eothermel(Closed loop) Mincer FROM TO •DESCRIPTION(color,tutaea+,Whelk type,(ato oso.eta.)
CIdeothennal(Hestia Cooling Retwn . ElOther(explain under Jai Remarks) 0 ft' a. D' ro t S c t L.
m /o >w -TA-+,-L. CLAY
4.Date Well(s)Completed:/1//8/ Well IDA f O ft. O fr. 7, i S44.1 L/CLA-`(
5a.Well L9catlon: - a o ft So n e_ SR•.%.t 6 J C Li '-( •
SO IV Yµ L 66R/FF(n! o n'° 70 ft. 2 t✓7 ca-ri-V/.S_r.-1,e,L.c_•_
Facility/OwnerNamc Facility!e(ifapplicablo) Q! r •.#�:"t;i:�, ra; .
�G � O it° %'✓i+�1��SA�.1�r/$� �tr r tiJ li
-`/S"s— up.,i-ri=l4per /-t�e.-C oe_h,Ale.a`79 tf a ft. ft. •I i
Physical Address,City,and Zip It BE11lARK3 NI'V 08 2023
• •
Peecau; i s L. ,. . .. :.. .,r_-- ..
County Parcel lder�tifieationNo.(P/N) C. >a:4w
S.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2L Certitieadoa:
(If well field,one tat/tong is sullclant) •
SG . 1 SCF 71 N 7(v. 37 537 w ': ci. b.) S'I' Trr- /o//9/a3
Signature otCortit led Well Contractor Dote
6.b(are)the well(a):1ermanent or DTemporary By stow thtaArm,I hereby cart&that the went!)was!were)consfumed in accordance
lvtth 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an enlisting wet: °Yes or , Io copy of thts record has Start provided to the we'ou*rrern " _"-
gilds is a.rpaJ thin out lemon well construction1t{formation dndexplain dfs nature 4fiha .She diagram or additional well Mans:
071 muarlascctla.Drew the back gfthisfarm You may use the back of this page to provide additional well site details or well
• 8.Number of Wells constructed: • construction details. You may also attach additional pages if necessary.
For multiple Injection ornon.water apply walls ONLYwith the stone aotptraction,you can SUl1MMiTTAL INSTUGT10N8 I,
submit enefms�,.
itTotal well depth below land surfaces 1 o (ft.) 2Aa.For All Wells: Submit this f Dint within 30 days of completion of well
Par multiple wells Flat alidepJha(/'diJJhrwn(erample..10200'and VIM construction to the following: 1�.• i
W.Stable water level below top of antlogt /0 (ft.) Division of Water Reeon1rces,lnlbrm0tlon Processing Unit,
fseater e Lc above=Iv use..+. 1617 Mail Service Center,Raleigh,NC 276941617
11.Borehole diameter, Cu (in.) . 24K For Infection Wells ONLY: In addition to sending 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: /'1'L t/b. tt-2/ construction to the following
(l a tary,auger,ro ,cable,direct pwus,etc.) • Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mali Service Co i ter,Raleigh,NC 27699-1636
/Sr Method of teat; � �w'ttA 24c.For Water Supply&Infection Wells:
I3A.Yield(gpm) Also submit one copy of this Soirtt within 30 days of completion of
C l4t_C+vt%).f yeoei•ieo ii-TQ 13b.Disinfection type: Amount: (e.Cr . ° well construction to the county health depmtmerrt of the county where
constructed. ;
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Farm tiW1 North Carolina Deponmentof Environment and Natural Resources-Divlalan of Water ttesourecs Revised August 201:
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