GW1--00263_Well Construction - GW1_20240105

WELL CONSTRUCTION RUCTION RECORD(QW^ll Fot Internal Use Only:
1.Wed Caatratier hibrusidon.
Xf s'�A- r v �ir SS e T f e ._ 11��1ldt>rdlillr{_
wen CoatresttrName ,!'BOSS To DtsCRWi]Of _ _...
(OJ IL ft.
9
/L it.
NC Weil Contractor Certification Ember / 1 QUR� ,
�:S.i tr'l�t 14 `j, /DR1l/1 1 Y)Lit` 1Li�r ft--PROM1O DIA1Ql�! .. illAriilAC
ft. la. ` r
CompnnyNaa* - / + t.
2.Will Coaa nicSea Porait 4: i -MA 9k . 1.111 _'..:ear i� "g.g I. ."
Thai _ TO DIAt1QilR . i l[AliYlAl
Lea all applicable moil awrtrsiction permits it,.f1IC,Cowry,&ate,Variance,eta) IL ft. Is
3.Wd1 Use(cheek wed nee): ft. it. la.
•
' miaow
Witter Supply Wei: - FROM TO DLeMesa snot 102 rrnac aNTli 1 sinIU.
•AgriculturalMunicipaUPublic ft.ft. la
S geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. rt. I.,
•f tial/Coounercial Residential Water Supply(shared) a�ra. -- .r.----..
PROM TO MATWAL A Cann CLsfril'r 111180 4 AMOWi4
Nee-Water Supply Wed: ) f �<� ", 1fna ;}
■Mani ', °Recovery it. rt.
--�
fr. ff. 1
•Aquifer Recharge °Gaamdwater Remediation _ .
1i► YIieFAI4 oseish*
I Aquifer Stange and Recovery °Salinity Barrie PROM TO MAMMAL t pf,AcsatxNT twstrgop
w■Aquifer Test 0Stormws Drainage IL rt.
}
• Tec hnology °Subsidence Control ft.
ig a „. • (Closed Loop) °'Crecy 11 IAA fiipMh saldiri aifitetis fl�ser; emit
•(3eotberrnal H- ,. eosin Return •Other -. .lain under#21 Remarks FROM to Draciurnor+tees.■,r.da.ey.sahrrh ayl4 sisal*a,.tee)
R. rt.
4.Deis Wen(*)Caapleted✓eglit1/., Wcdl IDM- 1 ft.
� _ P s-. I r
Se.Well Logsdon: ;.-tit'(r,f V f�. `ti
ghipald T T- 4/ .. ff. ft. r Jwti a ZOZ� L/
Feedity/OwarName Facility iD*(if applicable)
3145 0.th..• ' i14 v /le ,ice(6,-78`s( ft. ft._ �r,e-�;, --_
Physical Addis.City.and Zip
f /ASH Bike/e RJ40'-. & - , _._.
Comity Parcel Identification No.(
Sb.Ladtnde and longitude in degrea/minotedsecoads or decimal degrees: _—__ _____
(If well field.cos le/bag is sufficient) / 22.
Certideadea:
4/ N .,'U/ w )f//t-Y)i,, . , }'l.2f/a12
6.In(are)the wed(siPermaaeat or °Temporary Sias cure ore/Maul Wen Contractor bate �
B'stinbeg An fore i hereby certify Thal the sails)was(were)coastrect.d In acconiaeae
7.Is this a repair is as existing well: °Yes oro wok ISA NCAC 02C.0100 or 1 fA NCAC 02C.0200 Well Coweprction Srr,dants and that a
�/th&it a repair,jilt oat bgowa well Conro tlon information explain bit nature of the copy of rhea record has been provided to the well°weer
repair wean CI remarks section or ern,the back of this for,".
23.311e diagram or tadditisnst well detadi:
B.For G. obe/O T sr Closed-Loop Geothermal Weds having the sane You may use the back of this page to provide additional well site details or well
construction.only 1 W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
chilled: 9/7 $UHM11T'TAL INSTRUCTIONS
1'1 ot:ai well depth ~lead�� ° (IL) 24a. Fqy All Wells: Submit this form within 30 days of completion of well
For amfgpi.sidle!lot all dapMs y'dtiFarwr(example-3(200r'sand 2®100) construction to the fallowing:
10.Stade water level below Isp of casing: gt1 _(gt) DIvi dos of Water Resources,Infoneatiea Processing If wrier level it above mating use'+" Usti,
/ I 1r 1i17 Madaste
Service
Cr,Raleiely NC 276ff-1617
11.Borehole diameter: ;r ' Oa.) 24b.for b lectlea WO. In addition to sending the form to the address in 244
/� /_ jr...- above, also submit one copy of this form within 30 days of completion of well
12.Wad esoatreedsa»ietbed: I,G Vconstuction to the following:
(i.e.safer,rotam cable.direct push.etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Iajectlon Control Program,
/� 1636 Mail Service Center,Raleigh,NC 27699-163i6
13a.Yield(um) /±) Method of test; f /Arilsly,„,.-- 24e.For WitterSaimilv&lnkctioa WA: In addition to sending the form to
� the address(es) above, also submit one copy of this form within 30 days of
Dia 13b. lsfeeds@ type: r�)l:.diti""- Amount: .Ad}1-0 completion of well conatniction to the county health depattment of the county
•
where cons rutted.
Farm OW-k North Carolina Department of Eaviroacaana t Quality-Division of Vistas Rosman Revisal 2.22-2016