HomeMy WebLinkAboutGW1--03365_Well Construction - GW1_20240610 I \.
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use CMIY: \
1.Weil Contractor Inferntatiese
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Welt Cognacs Name 11111112 st.
:_..kiS, 6 --A 11111131111111113
NC Well Connacex Catificatiaa?.;x4alser '. -__.S.L..9.1_ COM '• - - MUM* - -
At%i C)a in \tacit S, ViAmP IL aA
amurgiu,!iita 1 gm=
Company Warne
fL 1-1 A I 7 -00)1,4 ri= unnownig nocacesi itrumlimm
b."'ntian -ma conzaut.....axes;au 4C.Ki.....C‘antg,*tab , __.
3.Welt Use(cluldtwdlint) -11.- ft.i hal -----1 • -
Water Supply Welts TWO! T° IPOTAEnta"likarSit _macsasss ?tallow.
in Agricultural DidooicipalTabric R. a. ha
OGsolhomtal(Haning/Coofing Simply) taltesideaftal Water Soggy(siogle) ft ft. fa.
OlodustriaLCommercial
rihsiaation mum : To —MATENIAT. OVILACOMpiT METHOD&AMOUNT
Non-Water Supply Well: - — -- (7 ft" 20 ft- il/71011‘t .4eaff&
CiManitoring CiRecovera,- ft. ft.
!Media R. ft
Wdl:
°Aquifer Recharge °Groundwater Ranetinhan
7 ea SANINGRAVEL IPACiiiraillancablel%' .." . .
°Aquifer Stooge axid Recovery 13.Seklityileceiet MO% TO EMPULTMENT METHOD -
°Aquifer Test OStonnualts Win' age a. ft.
Daperimeotal Tochnoices °Sabsideace Castro& ft. ft.
°Geothermal(Caned Loop) °Tracer ntavitauttG IniG baser sasitianid stielti iroteensaly_...••-- •''r. 'e.
Med -TO arstairranig fouhF kgrallus.airradkIlype,grab sla.ett)
CiGeOdleoOTI(FicatingfendittF Rana) nOliNT fiZILTITS Onderai RalTittS) ft..
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4.Date Well(s)Completed; c-61-VI Well Mg , ft. ft.
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Sa.,_Well_ Locatioui , 15 IL i)0 II- , f c4dt'l ZaCH,
‘,. poi btokit51‹, . .. 1) *- t23 . g rewk‘ Cncit ,
acitivot,-.14. faraTte-1130fiapplickle) i-L3 it 156 n• Oca4/14
3Iy3 13YrI;15aftl' P I . ft.
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Physical Address,all.*i:04 ZIP
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blir,,,e)bl 1 1. , . .... ...2 .. letelq":i
• County Perest Identificatuas' No_(PK) Jua 1 0 zon
5b.Latitude and longitude in degrcerinion' tesiseoands ardecimal&gee=
(Owe!!field,one la/lc is sufficient) 22 Certifies'
3C .E6S/71 N /.32/6'1 W %Thiormat„tvt rt.Pc:6.3, 41r.oH. Mg U'IL
inissrure ofGensfied eli Date
6.Is(are)the wd1(5)63Permanent ar°Temporary
By snug des for o 4 I hereby orally tint the%AV wII.1(we)constrocted in accordance
7.Is this a repair to an misting well: ElYes or VAN) wilds 15.4 NCAC MC.0I00 or ISA NCAC 02c.tedo WO Constreetion Standards and that o
'TOO te a repair.fill met bows well constreethet tajonoothet the egeloin ika Raw,of Me coPY°Phis'nerd has bet!Prvoitkd a/tie SVII'MOW
repent.carder 421 nortab:tyska,or me the back cithisfoon
2,3.Site Chagrant or additional well details:
You may use the back of this page to provide additkoal well site details or well
8-For GeoprobelDPT or Closol-Loop Geothermal Wells having the woe
=sanction,only I GYM is noxied. Indicate TOTAL NUMBER ofsvolls construction details.Yon raay also attach additional pages ifnerescary.
drilled: suBmrrrAt.INSTRUCTIQM
9,Total tall depth bdow land=face: (ft.) 24a./qr. MI Welly Submit this form within 30 days of completion of'well
Form:Velma/lad eil depths frifferere frozetple- 0'and aglag) constructice to the Mowing:
10.Static water level below top of=saw 30 (it-) Ithision of Water Resostroes,Jisfoemation Processing Unit,
!Pager lgwl is above easing,use +a 1617 Mal Service Censor,Babies,NC 27699-1617
11.Borehole diameter: (9 le (l...) ua.F,.. . ,- Well= In aelditioa to suartag the forth to to address in 24a
above,also submit ono copy of this form'Mint 30 days of completion of well
12 Well CarrithleijOn method::_--41.1- tefidt Art_ censaaction to the followinx
(Le.raier s ,rotary,cable,direct punt,etc.)
Dibtaioulaf Water ltemarces,Underground lojection Control Program,
FOR WATER SiiiPLi Mil,-LS ONLY: 1636 Mai Solite Casers;RakiglaliC 276994636
1.3a.Yield(gpso) P mdbiemniaft A.ir !--if+ 24c.Er,...,.. sr_sme&Ajostaistl."Lsv a: ht addition to sending the form to
, . ..
the address(cs)above,also submit ow copy of this form within 30 days of
13b.Disinfixtion typ .,.(jcr-i 4 e., A.,...ft 11 Cl.. complotica of via oomaractiat to the county health department of the county
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