GW1--03874_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contractor hifirrattor:
TO
won
ill-e_n
idCaotructe�../N"s s
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NC Number , 's 1 .[ � y, . -.j.,, 7-i— y4
�/.5.6C e- We—// /)b<I'/l; 6— ,fit n m n_ J
Company Name
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2.Well Caste retie■Permit 0: ^ ^-2 _5 a-9 ?O.. =m — . : "unmet.
Lot all ggr0oabk wall eareartietiaepared&(Le.UI Cornry,State. Variance,etc) h. lit. Ia.
3.Well Use(cheek well.sae): tt ft, r,
___
Water Supply Well: ".. ,. 1. , ,,......._..,
_ _ _
•Agricultural Municipal/Public n • ft. Due ROT slAitiRlAt
#Geothermal(Heating/Cuoling Supply) ridential Water Supply(Tingle) a It. bk.
•Induatriai/Coromacial Reeideetial Water Supply(shared) -
Irrigation ro 1 M uTr�tLat. iit cal urri 'glop.Aa r
Nor.-Wader Supply Well: I " t) ft. C a A e:
■ ', °Recovery n n
is n
■ • far Recharge °Grormdwater Remediatim .,
• Aquifer Storage and Recovery °Salinity Barrier �{L X t_Y
'»1�utatsi�l'f 11Q18QD., -�
•Aquifer Teat DStotwwater Drainage it ft.
•Experimental Technology QSubaidecce Caotml ft. it
• -•,• (Closed Loop) °Tracer �LLVOIDxl# '•i�iii it el etii . `�.-�_ _.. .,'I
■Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks m (sets 6iea••r5 slot ndc t)7e,la.l.+dG e052 _
4.Dote We&(e)Completed:fj1 Lv'l f Weil IDM, '7 3 (rr8 ft. ft
— n n
s. Woe Locates: ft. ft.
i_
laaciUty/Owar Name Facility ID0(iftappliable) R. 1t i ( , 1
.LLLLe sra c.Jk ied G8A 1'ley d 7S07 __ n ft. u,u:,5 ,, . ewe. : .ale
Physical Adrbees,City,toad Zip 1t 1t D,/,;:a w.,_
Canty Parcel k sen&s oo No.(PIN)
Sb.Latitude mad tsagltude in degrea/niauteNaeconds or decimal degrees: — t
avail Said,tee Intim is macaw) 22.Certification:4.Is(are)the wee(aa?ermaaeat or °Temporary a,7221X.
of CertiSed Wellaat .z.....ja.s.
l' , f
pave
By signing this farm I hereby cm*that the well(s)mu(wee)cosutructed in accordance
7.Is rifle a repair to an etdsdng well: °Yes or o with I.SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
'tints It a rep*,flit out keowa well construction information opiate the nature of the copy of daft record has barn Prrivlded to the well orrer.
repot,.weer 421 remarks section or as the?tack of this fora. 23.Site diagram or addltiaaal well detect:
R.For PT or Closed-LoopYou may use the back of this page to provide additional well site details or well
(Ci oprobaJD Indicate TOTAL Woes having the same construction details. You mayalso attach additional construction, i OW-1 is needed. NUMBER of walla pages if necessary.
drilled:
j)URMITTAL 1NS'TRUCTIONa
e depth9.Total depthbl lan ow d carfare: et, (a') 24a. For All Web: Submit this form within 30 days of completion of well
For mad**walk kiss all depthe lfdefmst(maple-341)2 and 2*100') construction a the following:
111,State water Mal below tap of cuing: (ft) Wilde*of Water Resources,Iafortnatioa Ptroceaaimt;Leh,
Vaster ie e/1t above casing.am//"+1 1617 Mail Service Cantor,Raleigh,NC 27699-1617
11.lforeMlt drn laetltr: to I.uP _(le.) 246.For Infection WO: In addition to sending the form to the address in 24a
/� above,also submit one copy of this foam within 30 days of completion of well
12 Well eaaaaaction natured: !.G --- construction to the folltmviug:
(t.e.wpm,rotary,cable,direct path,ace.)
--.i Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WRLLS ONLY; 1636 Mail Service Center.Raklgi,NC 27699-1636
13a.Yield(=pee) 'r•" Method of test: p iti12/2-- 2/e. For Water Suanly&laleetioa Web: In addition to sending the form to
the adeireas(es) above. also submit one copy of this farm within 30 days of
13b.Dbhrfection type: Amount: / completion of well construction to the county health department of the county
where constructed.
I
Form OW-1 North twine.Department of&wise:rmenml Quality-Division of Warn Ratuuroes Reviled 2.-2241016