GW1--03868_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only.
1.Well Contractor Information:
Cfa n P - - FROM TO DESCRIPTION,,; ,,�.1 :.:: :,,
Well C tractor Name H. ft
W636-A ft, ft. '
NC Well Conleaotor Certification Number ; 'b011)1{t:°04$),W,4y(fie4)i Mt!,w ii 1 o i .]ji-s'j,2' (P': !; l'c':Hli3
DIAMETER THICKNESSSSS►►► MAT RIAL
�� ��� PROM TO i,.s/� in, ���
G��t�Os � P�►�P � H. �o ft. 6,, ,(A� �4�7
Am
Company N mo 46)Iy tiv t($Xllf (.Qk , 1E)i(t'•'( ll l~ t,i. liMMINIMMIIIIMI
n�2-34 0 /`i FROM TO DiAaIETER THICKNESS MATERIAL
2,Well Construction Permit#: J `(C� ft. ft, t"'
List all applicable well construction permits(Le.U(C,County,State,Variance,etc) I n,
3.Well Use(check well use); ft. ft.
'.;11e1SQ .fi<'i C`s::tclli:e s.?t?—:ii.i'�r:k.�.tir --: -::;'.'i • i:'',.• :f;': r,
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
al/Public ft, ft, In.
[ Munici
QAgricultural p
a Geothermal(Heating/Cooling Supply) illtResldential Water Supply(single) fL ft in. • —
Residential Water Supply(shared) , �� s .v , '' ar vt h ,< . j,r+i r ar:=
IndustriaUCommercial aFROM C4(1 '� + '`' "''
PROM TO MATERIAL EMPLACEME. METHOD&AMOUNT
,"°pIrrigatlon � R.
�O ff° � 1�� . 'p t �� �j
I Non-Water Supply Well: { f
iggill
Monitoring Recovery it. �r'
Injection Well: ft. ft,
Aquifer Recharge OGroundweterRemediatfon '19,1 �T�p/Ci L-'PAQK}(IJ '!llegeI Fr x'''
Aquifer Storage and Recovery'
ecovery oSalinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
—
Aquifer Test r Stormwater Drainage
Subsidence Control It' f t'
Experimental Technology 'ti'�; dl'one '"
1 d'TI tit'di8i9' e(a'it did!` l •e .eaue
Geothermal(Closed Loop) OTracerOther P:L TO DESCRIPTION color hardnen rol Urock a rote size etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ) rt.
�Q ft.
(J i a
welID# 7 I ft. 250 ft.
4,Date Well(s)Corn�tleted:6-7-2Li '
it, ft, _
Sa,Well Location; ft " . '
G I '. 'Q fL '•:_ ►eA.
Oafl�✓PX7� Cf�m Q S JiI�Y I�SDY� ft. it,
Facility/Owner Name Facility 1DN(if applicable) t t;r! " ° �n�e
LULY Q L /� ft. ft.4 �Pjt,t�(JT t.V✓Y7ll� � ft. ft, (fotel ftivr.1 i,'-'4•Nq;-a Urst?
Physical Address,Clip,and Zip �yt`rt. aj
it''j�t�'+�Y11+�41f1�'�'.`il'rci�•�u. wi-
lasmommm
County Parcel Identification No.(PIN) -. '
5b,Latitude and longitude in degrees/minutes/seconds or decimal degreesi ; —
22,Certification;
Orwell hold,one let/long Is sufficient)
gCC�o Q ��
3Cj.670 Q N —V W C�li 77 L9,t / / '
Slgnah!ro of.,• Ified Well Con cror Date
6.Is(are)the well(s)'�i Permanent dr Temporary
By natures this Ilia (hereby ee ct or that the well(s)was(were)constraered In acco+dance
7.Is this a repair to an existing well; QYes or eNo with 15,4 NCAC 02C.0100 or IAA N.CAC 02C.0200 Well Construction Standards and that n
((this Is a repalr,Jill out known well Cops(ructlon Information and explain the nature of the copy ojthls record has been provided to the well owner.
repair under k11 remirkssecrlan or on the back of I/its focal. 23.Site diagram or additional well details:
•
You may use the back of ihls page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop rural Wells having the same
construction,only l OW-1 Is needed. Ihdlate TOTAL NUMBER of wells construction details. You m ay.also attach additional pages If necessary,
Indicate
drilled: SUBMITTAL INSTRUCTIQ1
9.Total well depth below land surface: ad6 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((d(ferent(example-3Q200'and 2@l00) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
((water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (tn.) 24b.For Infection 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: pQ 1..ctv'y construction to the following:
(I.o,auger,rotary,cable,direct push,eta.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
10 0 Method of test: r r 24c,Ear Water supay & Inieclttonells:W In addition to sending the form to
13a.Yield(gpm) q" the address(es) above, also submit one copy of this form within 30 days of
Cy1�dt l ✓i Amount; completion of well construction to the county health department of the county
13b.Disinfection type: where constructed,
Form GW 1 North Carolina Department of Environmental Quality•Division of Water Roaourcea
Revised 2.22.2016