GW1--02497_Well Construction - GW1_20240422

117
WELL CONSTRUCTION RECORD(GW D • . For Internal Use Only:
1.Well Contractor Information: •
• Well Contractor Name "34FROM TO »CPIPITON
1( �1." -� O m 34'4 ft' . r�tray-- a Eq
9 it. f. 1
NC Well Centredoi Number , . .
b e41 �r;11 i� I ( a c Sec D MATERIAL
Company •
f' 4-6' b. W t e-
2.Well Construction Permit if: ® a O© `{'S . FROM .TO DIAMETER THICKNESS 'MAMMAL
• List all applicable well construction pamfta(La UIC,County,State.Valance,eta) ; it ft. • in.
3.Well Use(check well use): ' in.
Water Supply Welk • FROM . TO DIAMETER SLOT SIZE •Tfficori s MATERIAL ..
■ .. • blic ft. a in.
■Geothermal(Hatmg/Cooling SnPPIy) >�sid Water Supply'Oink) ' ft n: In. •
■industrial/Commercial • 13Residattial Water Supply(shared) . .- •
IIirrigation . .ti • FROM TO MATERIAL EMPLACEMENT T MKIHOD a:AMOUNT
Non-Water Supply Well: • • d it ft: �D..11C� 1-� b S e �6k.b
■Monitoring-_ _ -Recov Y — tr. (k; ie_" i
Qt�tl,�'�=-�`
ft. ft.Injection Well: . . • •
/,_
I Aquifer Recharge Dt^rtoundwaterRemedielion
ti • • . 1 Storage and Recovery ElSalinity Barrier FROM • To MATERIAL - EM re ACEMtENT M eiHOD
■Aquif r Test DStomtwater Drainage . , ft !t. .
. ■t• •,-• .•.., Technology DSubridatceControl .. ft. !L • .
■Geothermal(Closed Loop) DTiaa r .. . . ,
FRIOM TO &don Wilma, hype. der,der.)
I Geothermal(Heating/Cooling Ratan) [Other(explain under#21 Remarks) 1 E
4.Date Weli(s)Csmpleled:_31 l S.)a 4 Well ID# . "1f7 . `j44�f.- -).(�—r— •�"'�`
sec.Well Location; 34=� :Vr5..'/ �C '_ ..c —�..=
'( ti:.f u5 'k0 I a h . ,i1C:. %4 f. 4-0( � - Cs 7-= :rtt '�'k' •y(i )'"`
• Faciliitty/OwnerName , - FaciilityID#(ifepplicable) ,' .
4-0 Are re 5 • PO•n Q;d- �,rJ��t� A r'fl: r ZGC"" .
;, lA a,City`e�ndz� 1 ft. ft. a�4 UttN
• ohCGo-w.siY_3- • 6$ 6 4-9 413
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degt ees/minuba/seamds or decimal degrees:
(dwell field,one htMng is sufficient) 22, n: .
866 3g130I K N %a ° 60-I 64- w ‘j 4
—' , 2Ic g j 9-4:- .
- _•_6.Lane)the wel(s) ermanentJ or DTen:porary _ . _ of ell Conlnctor
83' • this fans-.I hereby cer4 that the wigs)was(were)caudrxted in abeiudince
7. s this a repair to an existing well: QYes or .kiNo • with IJA NCAC 02G.0100 or ISANCAC 02C.0200 Well Construction Standard:and that a
(this is a nth fll out blown xeAaoaamucNaa h bn,ml:on and explain the now of the copy ofthie hecoid has been provided to the%O l owarr
repair router#ZI remarks sedkvt wan thebock of this fem.
23.Site diagram or additional well details:
8.For Geaprobc/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 . canstiuctioa details. You may also attach additional pages if necessary.
drilled: SIJBMIITAL INSTRUCTIONS
!.Total wen depth below land snrfia: 4-0 S (1) 24a.For AD Welk: Submit{.this form within 30 days of completion of well
-For nadtiele%alb list all d er frd{ifarsnt(ample-3(ai200'atd 2®1001) canatructiam to the•followingr 1 i •
10.Statle wale level below top : (ft.) Division of Water Resources,Information Processing Unit, • •
7fxetealevd is above cash fare +^/ 1 •
617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �j ( (in.) 24b.For Infection Wells: li r •
addition to sending the form to the address in 24a
12.Well construction method: 1LO mac r above,also submit one copy of this form within'30 days of completion of well
(ia ange.Mary,able,direct push,etc.) eonetrtrction to the following
n Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gyre)-. • to Method elitist AJ • 24e.For Water Slimly&Isiiedlon Wells: In addition to sending the form to
1'� the addreas(cs) above, also sobmit one copy of this form within 30 days of
13h.Disinfection type:. li1‘ - • Amount 0`i- " completion of well constructio 'to the county health department of the county
where constructed.
. PoemGW 1 • . . NorlhCeciiiaDeputi nisttofEnvironmentalQrmlity.DivisionofWaterRceoaeee Revised2-22201