GW1--03560_Well Construction - GW1_20240612

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----WELL CONSTRUCTION RECORD (GW-11 For internal Use Only:
1, ell Contractor Information;
Ct r�r I ! 1'fo 1'10 r tkTW t "?' D1:9�,G �'RJP I e N„NY,. ,, .. ..
PROM TO
Well Contractor Name ft. ft,
0 5 `I 5 -A ft. ft, ,
NC Well Contractor Certification Number et1;dti`4,10DW(y` )1V4nY(t6> 11R k s liVO )}�D)�,�I'J il�'(l'c�Nl@f%:,;.
(1� L'I rLt1 Rolf e FROM TO DIAMETER THICKNESS MATERIAL
Company llama 4dlrt)Nt l?:s NM' MT.ll3'LT2II1 _AI•r 3 6,, .
L.WeilConstruction
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�fmac// -G 52 t PROM TO DIAMLUR i« MATERIAL
List all ppllcableb wel1l1construction
Permit ifsT!mrslructlon permits(I,e.U/C,County,State,Variance,etc.) ft. rt. in'
.)
ft, ft. In,
3.Well Use(check well use): 4r {.LY{ ;,,a; ,lj,,. „s,ikt;
�hlf�.Q��r ,..ti7�';•IV „- , .� �Y:rr�'y jr.,>'`,{7 i.b��;•1- .�atr'"..': ..f;`.r�>;� ....
Water Supply Well; •
FROM TO DIAMETE�}F SLOTSIlE THICKNESS MAT_
Agricultural QMuniolpal/Public ft. ft. ERIAL
In,
Geothermal(Heating/Cooling Supply) ,�Rosidentlal Water Supply(single) ft. ft. In, —
lndustria1/Commerclel DRosidential Water Supply(shared) '.1:sikAko �'ri;, ;IsY>' ;>;4;';t(`�' "'I-:`,..,tyYn4��•;y`!A• -f-,;' '' , �::
Irrigation PROM TO MATERIAL EMPLACEMfENT METHOD&AMOUNT
Non-Water Supply Well;
Monitoring [ Recovery ft, rt.
Injection Well; ft, ft,
Aquifer Recharge ©Groundwater Remediation "j , ;,.r,; s: ;:yf :,; :-r%'; .,
Aquifer Storage and Recovery' OSalinity Barrier FROM TO MA'1P_IUAL EMPLACEMENT METHOD
c fL f6
Aquifer Test r��; oStormwater Drainage
3� Y fL fL
Experimental Technology .t:,' OSubsidenee Control
��-�yy,Tracer :;X9„ Xsi b1i o'Ittti'ttapli.ad49 c sitIi f I Yo:.ea;,. . .,,.:';•;.:
Geothermal(Closed Loop) - 6 it PROM TO DESCRIPTION color hardnen solVrock :e •rain dxe etc,
Geothermal(Heating/Cooling Return) U Other(explain under#21 Remarks) 0 ft. q Q ft. C/,`/ .
4.Date Well(s)Cothlfletedr,3-13 %2 I Well ID# C�', ft, C.I5C ft. /�••
5a,Well Location; •
Th 00,,m let/C/4 Names (,oh ft, ft. •
,
om��on c�"'Q'Y '
y FacilityIDNs applicable) ft, It.
Fnolllty/Ow rNamo (IfPP ) —
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•
a ft' IIr;�:::.
' IS 93 /AAll a 01, Grb,�� ►�d.
Physical Address,Clot/and Zip }11 mo�,d,7�} :{��� ,;tu•
iht'��h
County Parcel Identification No,(PIN) -.,
5b,Latitude and longitude in degrees/minutes/seconds or decimal degreesi 22.Certification;
Orwell field,one IeVlong Is sufficient) Jf
35 .1-16C,353 N —�I. a9GIOO W . 6
l 3lgnatura>Jf.Gaditled o - �� z
II Contmopr Pate
6,Is(are)the well(s) Permaneat dr Temporary the
ai signing this form,1 hereby
NCAC 01C.0100 or ISAl650 1 CACs01C 01001Well Construction Standards and accordance
a
7,Is this a repair to an existing well; QYes or �No • copy oftlds record has been prov'ded to the well owner.
dints is a repair,fill out known well co/ssirucilon Lt/brmatlon and explain the nature of the
repair under 1111 re narkrsQctlon or on the back of(his fonts. 23.Site diagram or additional well details;
You may use the book of th
a page to provideadditional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only l OW-! Is needed. Ihdloate TOTALNUMBBR of wells construction details, You mr,a also attach additional l pages If necessary.
tSUSMITTAL INSTRUCTI4L'�
drilled:
9.Total well depth below land surface: A 29 5 (It•) 24a, for All Wells: Submit this form within 30 days of completion of well
For,nultlple wells list all depths Vd(porarrs(example.3@100'and 1©100, construction to the following:
10.Static water level below top of casing: (rG O (ft.) - Division of Water Resources,Information Processing Unit,
(water level Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
11-- • above, also submit one copy of this form within 30 days of completion of well
i
12.Well construction method: tt r-/ construction to the following:
(Le,auger,rotary,cable,direct push,oto,) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of tests
24c,E41'Water SunD►v 8Bf j^raerinn atilt In addition to sending the form to
m � A.r' the address(es) above, also submit one copy of this form within 30 days of
Amount; 2 U 5 completion of well construction to the county health department of the county
13b,Disinfection type; where oonsirueted.
Revised 2.22.20I6
Form OW.I North Carolina Department of Environmental Quality•Division of Water Resources