GW1--03719_Well Construction - GW1_20240621

F FELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
..v.ei; Contractor information:
C--s:ooher Greene - - _ .:. ¢ e
\ :' FROM , TO DESCRIPTION
ft. ft.
2'.35-A i
R. ft.
. Ce.inca::on Number
x.= ',t'vE__ �RiLLING, AND PUMP SERVICE INC FROM To DIAMETER THICKNESS
_ M.>TERRI.
s ft. ' fL %to
;•
-. > _ .Construction Permit Q 94-3
FROM TO DIAME L THICKNESS mA=SAL
,. LVariance.etc.) ft. ft. in.
:z.. rn:.rn'uc'tior•permit</i.e. 'IC.Caurn.State. _
i•' i se;check well use): ft, ft. in.
c:Su-pis Weil: .,..�,._ ,.
_ FROM TO DIAMETER } .. .-SLOT SITE THICIC�•Ea5 . MATERIAL
°Municipal/Public ft. ' ft. i in.
.. Cooling Supply) IldResidential Water Supply(single) ft. ft. i in.
: .', Residential Water Supply(shared) li _.
--..-;:;;c^ FROM i TO MATERIAL : EMPLACEME TMETHOD&AMOUNT
`;r.-Water Supply Well: ft. ia0 ft. �ndmix poured -
® 0
:`�`.••r:::ur ['Recovery ft. ft.
Lion Well: i
ft. ' ft.
,. R aree Doroundwater Rem •
,.. ., . ,. ._,_ edtanon
1.• ',.r s:Uraee and Recovery EiSalinity Barrier FROM
TO MATERIAL. EMPLACEMENT METHOD
90111,
..,.i:cr ,.'_ . ['Stornwater Drainage R. ft.
-\_.r..merrai Technology DSubsidence Control ft. t ft. '
.., Cosed Loop) DTracer c.,
'� FROM i TO DESCRIPTION(color.hardness,soiiirock type,grain sire.ere.;
,.:„sea:ngiCooling Return) ['Other(explain under R21 Remarks) ft. ft.
-.::a:c Weli(s,Completedip..7" 4 Well iD# ft. ft. - T
4`�L.)
ft. ft. : l •,� .J L.
11,,, a 11.1 °! ft. ft. t
t 11 r AA 9 l 2024
Facility IDS(if applicable) ft. ft.
1
W C08 Wards GApft. i ft, i lrs�t9::FAAtieil P.T.,:sought ui1k
J O
e Zia ft. ! ft, i ,.a' t Jt(�
Cleves '133 79 -,_ �. ... : .:¢_ . .
Parcel Identification No.(PIN)
. __.., ::icie and longitude in degrees/minutes/seconds or decimal degrees: I
. .,,:`.ong is sufficient) 22.Certification:
eil
. -Aelhs)riPermanent or oTemporary Signature of Certified Well Contractor Date
By.signing this form./hereby certi(s'that the welts'was(were)constructed in accord,,.:,,
-.:s:his a repair to an existing well: ['Yes or IgNo with 15.4.VC.4C 02C.0100 or 15A.VCAC 02C.0200 Well Construction Standards and:i:c:;.
...:71i ,ut known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
.. _. -:•mw ks section or on the hack of this form.
23.Site diagram or additional well details:
-or 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 we::
. .,.,.;::o . :) : (iV%-: is needed. Indicate TOTAL NL�1BER of wells construction details. You may also attach additional pages if necessary.
one
/� SUBMITTAL INSTRUCTIONS
..:a:sscli depth below land surface: d05/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
. .. ,. all depths if different ferampie-3(d 200 and 2 SJ00') construction to the following:
..-a-..'.. slater level below top of casing: 4O 1 (ft.) Division of Water Resources,Information Processing Unit.
cling,se 1617 Mail Service Center.Raleigh,NC 27699-1617
::.Bar hole diameter: 6 1/4 (in.)
24b.For Injection Wells: In addition to sending the form to the address in'=:.:
Rotary above, also submit one copy of this form within 30 days of completion of wei:
.:.:i el.construction method: construction to the following:
_ ... it :..,d:rec:push.etc.
Division of Water Resources,Underground Injection Control Program.
'•;,.sTER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
't eid,rpm; en pill Method of test: Air Blow 24c. For Water Supple\&Injection Wells: In addition to sending the form to
71 the address(es) above, also submit one copy of this form within 30 days of
..:;isinfec:ior,type: Ch orine Amount: 3 completion of well construction to the county health department of the counts
where constructed.
• North Carolina Denarrment of Emirnnnvntal(Malin..Ili.•;cinn of Wa+.-RKnttn-Pe R.o4•ei'+_1'L,:,c