GW1--04187_Well Construction - GW1_20240717

' For Internal Use Only,
WELL CONSTRUCTION RECORD (GW-1)
1,Well Contractor Informatio1. s
acy'//e 11-40- el— ITR•M Q� j:CRJPTIQN
WellComreotorName ft, rL
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R` ' o�q�i�6�L�ItlA'Y1fi�C11�l
NC ell Contreotor Certification Number a4 •t° 'l (e�..' `7_i'3`_h° Er y ')•S"'t)Iti ''
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FRO Q' DI/ ETE• THICKNESS MATERIAL
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0 �{��' H. C fLila�J In, jOR�j I
CompenyNe /_ / -�� ))ft ) uFROM To (� i .:).{{:{., n KN8K8 !ATERI L
2,Well Construction Permit#s 4f� --9, !& ft. It,
In,
List all applicable well construction permlis Q.e.WC, aunty,State,Variance,etc.) It, ft In.
3.Well Use(check well use); :.. ,'(l11at,'1Lf i l�tL'::t6• I MATERIAL
Water Supply Well: •1 s u o D L,,)h' I, a 0 s is Iris
�MuniolpaVPubllo rt. ft, in,
Agriouhurai In,
oolin Supply) Residential Water Supply(single) ft, ft, MI
Ocothermel(Heating/C B PP Y) � ,t n'r;,',;;p>i.:'`'! �-. '.
lndustrial/Commerclai DResidential Water Supply(shared) c o'I'f ,•'•''.iv:,., `s�'"'r(,I�0#''"�`'. "'- "''' :,,,,"
FROM TO be
EMP ACEMENTM'TMOD Si AMOUNT
Irrigation D it' ;LO It' be egg )2. I. .S .D cif e
Non-Water Supply Well: ft, tt,
MonitoringQReoovory —
Injection Went It, It.
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Aquifer Reoharge DOroundwater Romediatlon 9. L�aT r e7r 11LJ EMPLACEMENT ETItOP
MMINISMOMMIll
Salim Barrier ••0 o M T'Rf L
Aquifer Storage and R000vory � ty fL ft,
��`; v-�IStormwater Drainage
Aquifer Test fL ft,
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!.• • OSubsidenoe Control
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Geothermal
(Closedl o Loop)ogy w•,ti' ,aT i a_,o s `IliY7; It12111 fPdl'�"rf.6[o�16;�1f �
Geothermal �Traoor � 3 � � � ,
PROM TO DESCRIPTION color hardnsn toll/rock •s •rslnflu elt:
Geothermal(Heating/Cooling Retuurn) Other(explain under#21 Remarks) , tL �q fL Ct Y Saj , Z.—
o
4,Date Well(s)Corhpleted: 5 J [
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Well ID# •
g p ft. d ft. Iffiffillalligfaffallill
5a,Well Location; r ft. ft, I
140Il'1%'�Id ��, Pr cries - 0A ft. ft.��b,J ft. L c024
Facility/OwnerNeme. I/ I / /l 11 •
Fealty IDN(if eppl ebls)
ft,•
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Physical Address,City,end Zip y T,e It,
t4Da 11 ,:.,,, d', .,..G,; `:'`�+
County Parcel IdontifloetionNo,(PIN) _-.c
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees: 2Z,Corti cation:
(If well held,ono let/long IIsufliolont) •
35.6zq5o N 81.9 96'YI W 4r______i__ .� ��
3lgneturaof.GartitledWollConl oar Bat,
6,Is(are)the well(s)�Permaneot dr Temporary
By n t urng this form,I hereby aer!(ly that the well(s)was(were)constructed In accordance
with/i,i NC,1C O:'C.OIOO a;':SA NC.9C 0:C.0200 Well Canstl'UCilOn Standards and that a
7.Is this ep repair outto a n existing well; r,,I: r lOo �N lain the nature of the copy of Orls record has been provided to the well owner.
Ulhfs Is a re air,Jill known well co strueiion ht/brmatfan and explain 23,Site diagram or addttlanal well details: '
repair under till relnarkgseciton or on the back gfUds form.
use the back o;'ttrle page to provide additional well alto details or wet
l
NUMBER of wellsa oo You maylon rho b, You may pag attach additional pages If neces
construction,For Geo onl l O or is n ed�d. Il dloa a TO A Welts hBEng the eema
drIlie only I OW l is Hooded, I}tdlaate TOTAL NUMcrIBMI�TTAL INSTRU�IQI�$
drilled:
9,Total well depth below land tint Iacot 1 0 (tt•) 24a, For All Wellet Submit this form within 30 days of completion of well
For multiple wells list all depths(dl terent(example.3i 200'and 2®100) construction Mowing:
(� (It,) Divldlon of Water Resources,Information Processing Unit,
([wa
ter level is above caJingo er tic water level b top of casing: 1617 Mall Service Center,Raleigh,NC 27699.1617
,uss e"+" (In.) 24b. let on Wel(it In addition to sending the form to the address in 24e
]1,Borehole diametort / For Inabove,also submit ono copy of this form wIthln 30 days of completion of well
12.Well construction method:
Q r. . construction to the following:
(Lc,auger,rotary,oeblo,direct push,(Ito.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: t XInl °ntglig I In addltlon to eending the form I:Method of toed Q/ 24c,ForFor Water 4ur> 'the addresses) above, also submit ono copy of this form within 30 days o
13a.Yield(gam) completion of wall oor,stnlodon to the county health department of the count
C p r/ Amounts � whore constructed:
13b,Disinfection typal Rovlsod 2.22.20I
North Carolina Department of Bnvironmentet Quality•Division of Water Resources
Forst OWI