GW1--04503_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 171.
1.Well Contractor Information:
Well Centocor Name FROM TO DISRUPTION
NC Well Conhtractor Certification Number 1{^\1 .
CJ,�-,IJC�/11 C,O,- \ �Q�1 " J i 1 I C. PROM TO DL Er THICKNESS r MAMMAL
•.
Compeny Name 2.Well Construction Permit#:
6 a 4 — e o 9, 4- 1 FROM TO DIAME1IR THICKNESS MATERIAL
Lin all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL is.
3.Well Use(check well use): ft tit. it
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL .
DAWICUID sal riinlie ft. tit, is.
DGeothe mar(Hating/Cooling Supply) w Water Supply(single) tit. n in.
()Industrial/Commercial DResidential Water Supply(shared)
0litigation FROM TO MATERIAL WNACEMHStT METROmxruon•AMOUNT
Non-Water Supply Well: 1 0 ft. a.C t'• (otiCtz ‘`®( So 1 , Cc
DMonitaring ()Recovery !t. ft. °.l:);•Q10 h ; t e cec f o f
Injection Well: , P��• "
Aquifer Recharge D mundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMR.ACZMENT MI ROD
Aquifer Test DStormwater Drainage ft. it.
8GeolhermalExperi�l Technology ()Subsidence Control ft. ft.
(Closed Loop) ()Tracer IIIMIIIIIMMIIMIMIIIIMIIIII
M DEecRI!r[oN teetr,YaAasa aaRlraek t1P4�nlaa,ate)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM „ ,V v¢ b QM
,4� ft'4.Date Well(s)Completed: L J i 1 C `� Weil ID# ft'• i t S ft' &t.Qm-veN.7....
lk -�5a.Wen Location: 1 S ft. \1� ft. V C-_ `' VS
J ere v�- t s -h S k Yl _►2 c ft. 44 5� f'c% r. r`r-2 sty„,
Facility/Owner Nana 1 Facility 1D#(if applicable) ft. ft. .. . • 7
34 CAC I Lt- \5 I„►'\ I\S Nit 1 ( C ft. ft. — . ;,;••-..4. :/1 L.)
Physical Address,City,and Zip
1 1 ft. ft.
12)wI1CCv.V. be-, q\L` i n 5i1900t0
Canty Parcel Identification No.(PIN) dam:,..h. --„;....4
Sb.Latitude and longitude in degrees/minutes/seconds or dedmal degrees:
(dwell field,one 1st/long is sufficient) 22.Cert(tygldon: -
35 ,,, 35 / .3g ' N S c S 43'i W � . ,..„,,,,/... •
6.Is(are)the wens) ermanent or Temporary f Certified Well Co r Date
By signing this form,I hereby certif,that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: Dyes or DNo with 15A NCAC 02C.0100 or 13,1 1V CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out booms well caartructlon tnjoreation and explain the nature of the Copy of this record her been provided to the well owner.
repair wider#21 remarts section or on the back of this farm.
23.Site diagram or additional'well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the salve You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of welyl-- construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL 1NSTRUC ITONA
9.Total well depth below land surface: 4 1 ( ) 24a.. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths�dlfferent(example-3®200'a 2®100') construction to the following:
10.Stalk water level below top of easing: + J (ft.) Division of Water Resources,Information Processing Unit,
ywater level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (ln. 24b.For Infection Web: In addition to sending the form to the address in 24a
IL Well construction method: � _ above,also submit one copy of this form within 30 days of completion of well
construction to the following
(i.o.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(spas) \S Method of test t— + 24c.For Water Snooty&Inittlon Wells: In addition to sending the form to
,++ the addreas(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ,1�� Amount•. \6 t completion of well construction tion to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016