GW1--03906_Well Construction - GW1_20240628

_WELL CONSTRUCTION RECORD (GW-11 For internal Use Only: rry;: =
1,Well C,gn e sour o ' _ •
(/71 IfJ •
cilr�llr iS �li- NM ., Ll'alivk'%.',!5,.,.,/67,�;•'.',,;F;•;. •'i
^ DESCRIPTION FROM TO
Well Contractor Name ft. ft,
`7'� _y' Q it, ft,
NC ill Connaotor Certification Number ' oO rit�RY oY ''' � �dEg I fY4{TN THICKNESS ii 1iFR M�AIT&RIAL
�m J �i� �� � io 4,,171L , It,M j ft, )_In, 5i)�r�i / V c
' �7 RY its... 'M71. 1(4'i'b'itttf '�1ietiMii)'..�.>t(�,'�YV:•':;:,:;:':..
CompanyNartyl� b�/ FROM TO Q�vMETER THICKNESS MATERIAL.
2,Well Construction Permit N; �� � � `� ft. n, In.
Lint all applicable well construction permit:(I.e. U(C,County,he,Variance,ale.) ft In
ft,
Well Use(check well use); p-irl8k ?kftl4kt ��l 'r'u+ft)i;j+(' '.'rY 'tE'Ft�.+�.r x(:zr+;Si:•;.).,, ,ct�S.. :::ir r:i. ,. {
Water Supply Well; FROM TO ■ Dirk ill ETFR SLOTS=LW THICKNESS MATERIAL
Agricultural DMunlolpaVPublio
it, ft, In,
Residential Water Supply(single) ft, ft, In,
Geothermal(Heating/Cooling Supply) � pp yi
( g )
Industrial./Commercial 0Residential Water Supply(shared) gof{b t}s,;b)1rrvi i>4"imrig6fli v;•:f";'o,,•;',F:'.:`'"',4'•4..,'r;,'a .:4!; :. •
..'
OM TO ATERiAL EMP ACEMENTM'T OD&AMOUNT
Irrigation FROM
rt. )\O ft' '—;L 0 IAYe,a - 3 •h c S
Non-Water Supply Well: r
Monitoring QReoovory ft, I ft, —
Infection Weill ft, Ft
©QreundWeterRemedlall0n r rt ° fir;;'•. ',,, •,,:•J.�'.;'++;;; 71 `.:••.H.
•
Aquifer Recharge id'4hAI�1)/ZiRA' iL{ A, �• �a EMPLACEMENT ETROD
Aquifer Storage and Recovery ,' DSailn►ty Barrier ' FROM tt TO HILII ft,
Aquifer Test ` QStormwaterDrainage !t. ft
'w' Subsldenoo Control
Experimental Technology ,..... �i'e a `�•ell ' c�a•",l'-:�' ir(e:%e r
Geothermal(Closed Loop) �Traoor '9 j l;Ot G1� '�!k ,' E(p'n �9il
FROM TO DESCRIPTION color .0,i'•, ,oWroek , roln).;. Uv.
Geothermal(Heating/Caoling//Rotum) �J0Othor(explain under r121 Remarks) O ft, (D ,/ fL Ir 6t y
4,Date Well(s)CorhElletedl (p I °`�Well IDS Z S ft, `� 3). t, �yl/ f e
Sa,Well Location; It, It,
no /4,1& n t, ft, J�'1V `,� g Z�Z�
Paolllty/2Owner N I pPaollity IDh(If spplloablo)
Physical A dress Cl ,and Zlp, / w;l;. li•" ' ''-%•='�`^''
County
Parcel Identification No,(PIN) -
5b,Canada and longitude in degrees/minutes/seconds or decimal degrees; 22,CerdAcationl
(If well field,ono IeVlong//b sutllolont) ,�J /����
35• 4)4 I N - 1 W l�j� YJL Date
l °�
i Signatureof.Ca+llnad WeIlContra�
6,Is(are)the weU(s) Parmanent dr Temporary
By natsigure this Java /Well
C hereby Contra
y that the well(s)was(were)constructed in accordance
with NA NCAC 02C.0100 a.13A NCAC 02C.0200 Well Ccnslrao:Ion Standards mid that a
7.Is this a repair out a n existing well; ,'Yes or op No • copy,of this record has been F ro 4ded to the well owner.
Uihls Is a repair,fill knomt wall copsiruorlon hl/brmation and explain the nature of the 23,Site diagram or additional well details;
repair under H2I roinarkr.reptlon or on the back of this joint,
You may use the book of'this pogo to provide additional well site details or woll
8.For Geoprobe/DPTn, nlI Oor s needed,
it'Geothermal Wells NUMBER
the same
construction details, You may also attach d additional
pages If necessary,
dined construction,only I OW 1 la needfsd, Ihdtoete TOTAL LIUMBBR of wells �IIBMITTAL INSTRIL:lQNS
drilled,
ll
9,Total well depth below land eut'facet —
(ft,) 24a, For Ali Wells; Submit this form within 30 days of completion of we
—'—""—
Por multiple wells list all depths U'diQ'erent(example.J®200'and 41100) construction to the following:
(� (ft.) -. Division of Water Resources,Information Processing Unit,
1
If water l er water level below top of casing; 1617 Mall Service Center,Raleigh,NC 27699.1617
If water Is above casing,use"+"
(in.) 24b.For Inle We111[; In addition to sending the form to the address in 24e
11,Borehole diameter: above,also submit ono copy of this form within 30 days of completion of well
12,Well construction method;
0 Y'u construction to the following:
(I•e,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY; t
f y 24c,Forger Wa____ ter ilEal3 R' 1n1�wells; in oadf ditionis to sendit within t30he
form
a h
o
13a,Yield(gpm) Method of test; the addreaa(os) ebovo, also submit one copy
I Amount; S completion of well construction to the county health department of the count;13b,Disinfection typal g�'// where constructed,
Revised 2.22.20I
North Carolina Department of Environmental Quality•Dlelalon of Water Reaouroea
Form OW1