GW1--03508_Well Construction - GW1_20240612

,L , CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information: •
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FROM ,,,,,..„.,:,, .:••,::•::•::.„ . • •
__
TO DESCRIPTION
WeIIConlractorNemo rt. ft.
145(-I 5-A n. rt.
NC Well Contractor Certification Number ;j'Cet h1t1l'%0400Afetldia'!)} .L0E4lti'jt01IN010apllchlo)% ;
CcA mp 5 We I I Gl1 d Pump Co. 1— ft. TO , AL
t. DIAMETER in. THICKNESS
ss MA L
Company Namo I I 1-647SNd, EitWOR? t;Mg tlighaMOia(`i6Yi i,,. . . .
2.Well Construction Permit#; 1'7•`r/�4+ 01 ZG 7 FROM TO DIAMETER THICKNESS MATERIAL
ft ft. In.
List all applicable well construction permits(L .e.U1C,County,State,Variance,etc.) In
fL it.3.Well Use(check well use): i s : " "'
Water Supply Well: FROM TO DIAMETER SLOT BILE _THICKNESS MATERIAL
Agricultural
OMunlcipalPublic ft. it. In.
Geothermal(Heating/Cooling Supply) "Residential Water Supply(single)
ft. ft In,
Residential Water Supply(shared) 7"'• p ..•�s e , r ; lr,,A?, � h rnb�. ) xr, .:�
IndusttiaUCommercial )#$(161`;�ll ��,�++..5�i'{�S ri +��`+, rr, ° •"j0•`
1,.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
: ri b ft' 9-'0 �•0 It. J;n;IC, 10 0s
Noonn-WWtiattee r Supply Well:
Monitoring
ORecovery rt. L rt.
Injection Well ft. ft. •
Aquifer Recharge DOroundwater Remediatlon i91.$A)�p1 rR%`a�,h PA S(Ul pp tail ll T� :. k . ' '# "''
Salin FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Storage and Recovery � a h'Barrierft. ft.Aquifer Test ',. DStormwater Drainage —
Subsidence Control ft, ft.
Experimental Technology [� ;, -
Geothermal(Closed Loop) OTracor 1: ��JA �' 1100t(PNaQ 'addltionPllbheeti t(i}ii'o i481ii,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/CoolingReturn) nOther(explain under#21 Remarks) O ft. 5 0 ft. GI /� r
4.Date Well(s)CoMpleted:05' 2�2 LI Well ID# 5 I fL I LI g It. (7tZM•1.e t-e.
l ft, ft, i.:� 7��1 v1t
So,Well Location:
rt. rt. •
April 6vr►�t�-iiAN/Cilr�yt'an 1-6ints ft. ft. — JUN 1 2 2024
Fac Ily/OwnerNamo FeotlltylD#(If applicable)
2.02-6 AfGrthStd-e, )2r' ft, rt.
t. D;:C:,3
LINGOIII
Physical Address,City,and Zip 3Yt',ItirjJyfA�148i�;4j�,,:gC`_:u:, •• .;. tin.';,`_4.:.. . ...; . •,:
,;• "�'. _—
County Parcel Identification No,(PIN) -.
—
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: 22 Certification;
well field,one let/long Is sufficient)35.1'i661 L18 N -81.0°I68'311 W P.e,.,,„t,____i
-�--,..,2
t�
l Signs ro of.Cettlflad Well Contractor() Dato
6.Is(are)the well(s)t�Permanent dr ��Temporary
By signing thisifiedorm,I hereby V that the wells)was(were)constructed In accordance
with 1JA NCAC 02C.0100 or1JA 'CAC 02C.0200 Well Construction Standards and that n
7.Is this a repair to en existing well; [ Yes or �NO copy of this record has been provided to the well owner.
If Is a repair,JIf1 out known well copslructlan Information and explain the nature of the Site diagram or additional well details:
repair under#21 renterksaection or on the back of this form. 23.
•
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 OW-1 Is needed. Ihdloete TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary,
i i1Y,,,rITTAL 1NSTRUCTIOIy$
drilled:
9.Total well depth below land surface: I q 5 (ft.) 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths ljdgerent(example-33@200'and 2@100) construction to the following:
10.Static water level below top of casing: 6 0 (ft.) - Division of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
(/water level is above casing,use"+"
11,Borehole diameter: 6 (In.) 24b.For lnieetlon 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:_121.L.k1r--Y..---------
construction to the following:
(I.e,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
Cj Method of test; t 24c,For Water SaoD1v & ing•tlon Welts: In addition to sending the form to
13a,Yield(gpm) I r the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b,Disinfection type:Chl Amount; where constructed.
Revised 2-22-2016
Form GW-I North Carolina Department of Bnvlronmentai Quality-Division of Water Resources