GW1--07223_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD For inttranaal Use ONLY:
e I
= his form eanbe used or vials
I.Well Contractor Informodon:
tat WATER ZONES . I i
l(h. .4C.1 eS 7 t`l FROM TO DESCRIPTION .
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Well Contactor Name let ft• No it c-c,40.sfc_i I G:wr E, lb Side vj '
NC Well Contractor Certification Number ' le•OTIT'ER CARTWI(rorattaiFE->;eeed Aveis)OR mutt or cep cable)
FROM TO DIAMETER THICKNESS MATERIAL
A-i�iLRICA•�1 k.ktk-LL_ 6( P- t+L) a 7o ft `D ice. SC l'Q PVC
Company Name 16. CA$iNG'URTIMING fUeaittttrmal cMleti=)oop)
A, MOM TO DIAMETER IMMESH MATERIAL
2,Well Construction Permit se: Y ft. ie.•
UM all applicable wellpirm&fi e.County,.I e,Variance,to orlon,eroJ
3.Well Use(cheek well use): • th gatErxt •
• twitter Supply Welk 1. violist To I DIAMETER; ( SLOT SIZE 1 TRICRNE9O I MATERIAL
DAgricuitural OMunicipallPublic tr. 90 ft. a as. , 0 20 Sc-‘0 o Pert:, i
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OOcothermal(tieating/Cool ins Supply) aftesidentialWater•Supply(single) ft. a. tad i
❑Industrial/Commercial DResidential Water Supply(shared} inn.;
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�r _ , F(tp]�1i p� IO AlATE�1AL � E61PLA�EMENf MSC!(08 iiAMOIIKt�
i Itatica a ft i3a ft. ° en Po v es.. 1.
___. Non-Water _.__________-_ __
ft. ft —
CIMonitaring OReeovery - - .
Injection Wells ft ft.
ClAquifer Recharge InGrotmdwater Remediation -19 SANDIGRAVEL PAClf tifamfttablel .
FROM TO MATERIAL ' larouC@NPNTDME UOD
[]Aquifer Storage and Recovery DSelinity Barrier . _. It, . c}o tt, .0 a azR AV L.. f OCJ LE
DAquiibr Test 13Stonnwater Drainage rt. • ft.
CLExperimental Technology CISubsidenoe Control
•20:sittLimkal LOG jothettidditionateaseisitaeseeisersi
DGeathe:mat(Closed Loop) DTracer FROM TO OomemPTIoN Kolar,treitteta,eaatraak type.We srmo,etc.)
GGcothc+ruat(]-Tend jCooling Return) - rsflther(exylain under 021 Remarks)` 0 ft. 025 B. 'r4 GL4 te
2.5 fL So f. G.%P_ y CL/l-k i
4.Ditto Wells)Completed;/Q/r9/ IDlI% SO L �� fG , , yr
9a.Well Location: SS fl. ,70 ft co E GC.t-1 r C,: saga b
Bo g6.y (D,tit 1 1-(L E-TT 70 ft go ft. t l_ I t r
Facility/OWENude . Facility me(if applicable) 9 o R, gn •
ft S ty / et,7.,r 5 _ r 1
I al �'&t'S 1_4 ,i-refer F6 6s( L 4-4 a.C. -4-1, �- ft . . •.•--„ n., ..•6. r. ,fx1 g.-® .,...,iPhyakalAddtess,City,and Zip •ZLREM 11 NOV S ZleZ3 .
`PER.OLs::0. hiS •
County Parcel Identification (PIN) i i f.r;7., `.'71?' 57, -=9 1;c1
S.Latitude and Longitude in degrees/minutestseconds or decimal degrees: 22.Cerdlleatlon. 1 �'� J y
(Ifwett field,one Moog is suffieicot) I+
C,2. i 5 `.-7 8 N•—76, .3 77 5? w ,,A, u.k.e—' i /0/r y/f,2':
Signature ofCortlfcad Well Contractor i Date
6.Ia(are)the well(S): 'ertnanent or DTemporary By arguing this form,I hereby cores that the rvaG(s),rue&we)coxsbueled in aecordan e
with 15ANCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction SYmrdeorls and that
7.Is this a repair to an existing well: DYes or JNo copy of arts record has beenprartdedro the welI miner. -
Phis isarepair,ft1 oat loom well c nstruefionhtkovnation andexplala the Haute glare .Site diagram or additional Well details:
repalrasdar aaI err vrarktseettoAoron the buck gf thi+form . You may use the back of this page to provide additional well site details or well
. ti.Number of wells contracted: • construction details, You may also attach additional pages if necessary.
For multipie Injection or non.weler supply wells OttLYwlth tire sante conduction,you can U)iMllTfAL INS fUCT1Q1tIS
submitsuala a.
9.Total well depth below load surfaces (o (ft.) 24a.For Ali Wells: Submit this form within 30 days of completion of well
Fee-a d apte wells list alIdepths ecletmit(example-3aQ20WmrdZ6I001 conslructl 11 to the following: f
10. Division of Water Resources,Inlbrntation Processing Unit,
(tw s?.lev water level below top o4 cueing: (R} 1617 Mail Service Center.Raleigh,NC 27699 i617
{(,racer terra rs above oaring,use"+••
11.Borehole diameter: 61 (iu.) . 24bt.For Inieetlon 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
12,Well construction method: )V (lo f A'Q y construction to the following:
(i.e.auger,rotary,cable,direct push,eta.) • Division of Water Resources,Underground Injection Cavilled Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 21699.1636
C-P-&iT 24e.For Water Supply di infection Wells:
13a.NM(Slim) P Method of test: Also submit one copy of this form within 30 days of completion of
CAI,CA V .hypo ee-i Lo a TE wellcvnawuction to die county had*department of the courtly where
13h Duainfeedoto typyp es Arnoun G constructed. I
FormOW1 North Carelbta Department of Environment and Natural Resources-Divialan of Water Rein= Revised August 203:
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