GW1--00898_Well Construction - GW1_20240205

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WELD CONSTRi3CTIONK )`:
• 1.Well Contractor Information:
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Wcll Contractor Name ft. ,[ rJ;"ft ��}� �-n. 2 r' �L 1'(c'1 �7 v
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NC Well Contractor Certification Number Fttost ro orAntl:Tra
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Company.Name ,r 1 FItU�1 . rtf - .111.4ml'.TF.11. YitrtcKhl¢a ,Lt4ITRI11 _
county,
ount,seattrxarience,mod 0 II! (7;L ri. / in.
2.Well Construction'Permit ft,rrmits ir.r;lIC,C. { ; ' . . 'tf<:_____,_._:.-..
} List all i,pphcabtt x all cartsYructttx!/ ft.
h } in f
r� �rltr;rtN
3.\\'c11,IJsc(check r�`cll'usc):: FROM •10. nrniiiSER stars •'rr('i�K i�a �r�r>,Jt- _
ai/Public ri. - __
\Yntcr Supply\\`c14 ��qunlc n i In:
Agricultural c�idcntial Water Supply(single) ;. n• fi ta`
jGctathcrmnl(llcatenglCooting SUPRt)`) DResidential Water Supply(shared) tti.c:RotrtT I
Industrial/Commercial - .inure TO :<tArt:RrAr, rttPIAI-TUE:VIM RIA/bt1.1At:7"r
itT1.,tnliln r r e. 1 -
Non-Water Well:Supply ell: Recovery It. rt. I ( s �._,
Monitoring : n. ri.
I injection Wen: � m
undwater Reedintion
19-.SAND/GittVEL PACKfIf npplieahre) -
Agill'fer Recharge •
°Salinity Barrier FRO►r TO MATERIAL EMPLACEMENT METItOD .
Aquifer Storage and Recovery co.a rt... " rt.
oStormwater Drainage
Aquifer Test ' tt. n.
°Subsidence Control
I?xperymcntal Technology °Tracer 20 DRILLING LOG(attach additional sheets IInecccsiny) '
Geothermal(Cloned loop) L..t FROM TO DESCRiPTIO`7 rnrnr bardnes salt/rack •cram%be.et,
Other ex lain under tl21 Remarks)..
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NcothcaI oolin Return): rt.- -f n. t _dl r;
Healin C I, `' ''jirSr�
'a � We11 HMI '- �" ! n..- la f f 61'r( �r
4.Date Well(s)Completed: _---- tL n' .
5aa..Well Location:: ti. n:
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ht1 e1"l t!Jr163L.L + - . ft.' tr ^j
Facility IDlt(if applicable)' 1'~`
Faeitity/Owner Tame �• 4° y r 9 f 3'. S
s< ��..,. ���.,�•s 1 e. M1lr. 2;4dd is n. n _ ' --
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PBysieal Address,City,and Zip 21.RF.AIARKS r,..
—; `y- Parcel Identification No.(P V ' • a;c,(r.-L
County. ,
5b.Latitude and longitude In degrees/mintites/seconds or decimal degrees: 22.Certification:
Of well field,one tat/long is sufficient)
gnanire of Certified Well.Chntractor Date
6,Is(are)the well(s) Permanent or °Temporary J
By signing this form,/hereby certify'that the well(s)was(wen)constructed in accordzuce
• 7.Is this a repair toan existing well: DYes or,QN°. with 15ANCACO2C.0100or15)1b'CACO2C,000 Well Construction S. rdrrr:dduea
j Ifthis is a repair,fill out*noun well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
rrpuirunder 1,21 remarks section oron.the back of thisform 23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this-page to provide additional well site details or well.
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary
drilled: SUBMITTAL INSTRUCTIONS : •
9;Total well depth below land surface: taZ d5 (ft.) 24a. For All Wells: Submit this form tvithirr i0 days'of completion of well
For multiple wells list all depths ifdiJjereat(example-3Q100'artd 2Lr 100) construction to the following:., "
10,Static water level below top of easing: as'fs7 oft.) Division of Water Resources,Information1'rucessing UniL/Jrs'r water level is aryove casing,use~ '^ '1617 Mail Service Center,Raleigh,NC 27699-161 d
11.13orehole diameter: G. Zr •(In.) '
py L 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.13'ell construction method: ih�fC y -,above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,ate.) / construction to the following:
FOR WATER iSt Pl'I,Y WELLS ONLY: • Division of Water Ilesayrces,Underground Injection Controi..Prograut,
• 1636 Mall Service Center,Raleigh,NC 27699-1636.
130.Yield(gpm) it Method of lest:VV.
-},�_`,/��-y��r ire'` 24e.i'enr 11 Etter Su a cction 1�'cll� .Lrutddition to sending the fount to
(�► � the address(es) above, also Submit one copy of this fount wititin`30 days of
13b.Disinfection type: '1: 1 Qt'r'yV. Amount; �,j
CJ� ' completion of well construction to the county health department of the county
• where constructed.
-Form GW-1 North Carolina Department of Environmental Quality-1)iv Sion of 1Vater Resowces Rw sed2.2?-201b '