GW1--02496_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: MilMgr
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1.Well Contractor Info on: ('
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FROM ig:M=i211 ,':CRIPiTON
Well Contractor Name- A ' t,fft.t L Mi_
r ' C'� ►A
1 GC_ - 1 0 -, ! .
NC Well Contrac ocCertifcaation Number .. - ••- •- • r ..;
V- FRO lc. /11'�I L11.1 r:I CN:Yaa.t:MI i .
P�t h �ci1� LeJ t\ Rr-..,\\1/4-�v., \ V C M ft o ft (fit In. Spt _ ( P4C
Company Nerve ' ? ,
2.Well Construction Permit#: �O a� '004� I FROM �9Ut•�,)INVA:1♦1i�Y:1te:41'k4. a:
List all applicable mil construction permits(i.e.UIC,Comity,&ate,Variance,et?) h . ft. in.
3.Well Use(check well use): ft' ft. i0
Water Supply Well: - ,, ,• r , '
�A- FROM �po LSY:4i.,'elcivA�`Y:ItN Y I:\� rs ..
�Agnculdual 1:1Mtmr ]tc ft, ft, In. _ —
Geothermal(Heating/Cooling Supply) DRQdential Water Supply(single) ft f t 1,n.
Industrial/Commercial DResidential Water Supply(shared) , •• - -- , • _.
hrlgation ��■ ►vY.A.4f'i�'1 IIr►T«M IJI r� I'Mr tr)Z' r.itra.11L7♦
Non-Water Supply Well: • 0 ft' orb l Q. . 0 a •.S ' . o a .
Injection Well: Recovery ft •
— - a ..a� p c�r�
It. ft.
Agttifer Recharge __ _ DGmuudaater Reunediation _.
_s- -gAquifer Strange anti Recovery. ' DSalinity Barrier lia:1111MMI o ll 4„1.'t N.a„I:n:r a:I.;Y,o)la.
,3AquiferTest DStom►waterDrainaage. . . ft. ft ,
)Experimental Technology DSubsidencc Control - , B. ft ,
)Geothermal(Closed Loop) DTracer • ' . / . `' ,, " , " ' _ , - ,, ,,; `
}Geothermal(Heating/CoolingRdmn) [Other(explain under#21 Remarks) it�•� tua:rrsa nrr--raur-z.,ice, rr-
t) h' �� 0 tiit2X' n cic4 e
4.Date Well(s)Completed: °‘,I a1 I a, Y Wei ID# RPM= �{N— ,`N--e-
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5a.WeDLoation: • ' 7 • IMI Ie}f 1 Ce — 0 0 0-tt'N
• Facility/Owner Name Q�AI 1 _ . FaciiitylD#(if applicable) f l.`4 ,. . w 'F I- t.•'
1�f`V tit hS ls'�� �e^-vt �� l,Q. ft. ft. A`a • 6‘ l 4
Physield Crty,
u.n c®t.v.bt• co 533-33 a 619
" [i'•rd(R 3
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or dedmal degrees:
(if well field,one lst/long is sufficient) 22.C cation:
% 0 A-a 4-1 - N Sa ° 3\ . '31 �� w -cJ `- '9,1a 4
3' ...-of•fi Well Contractor Date i
6:Is(are)Wewdt(a) out or TemporaryI '
By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance
7.Is this a repair.to an existing well: Dyes or o • with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well clnntraaction ainfarnwtion and eexplain the nature ofdue copy ofthia,record has been provided to the well owner.
repair under#2I remark section or on the back of this form.
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 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dam: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlerent(example-3(g200'and 2@100') construction to the following. I
10.Static water level below top of casing: on`0 /
(ft-) Division of Water Resources,Information Processing Unit, '
Ifxnter level is above caving,use"+"^ • 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: (a (in.) •
24b.For Infection Wells: In addition to sending the"form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
auger,rotary,cable,d rectl�h,etc.) construction to the following.
(i.e.
Con
FOR WATER SUPPLY WELLS ONLY: Division of 1636 Mall Service Center,Raleigh,eig NC 27 9-1 36rol Program,
1 NC 27699-1636
13a.Yield(gpm) t"° Method of test: 24c.For Water Snouts es Infection Wells: In addition to sending the form to
the address(es) above, also sutimit one copy of this form within 30 days of
13b.Disinfection type: i4T Amount: 1nA t, ' completion of well construction)to the county health department of the county
where constructed. 11
Form GW 1 . North Carolina Department ofEnvimnmental Quality-Division of Water Resources Revised 2-22-2016