GW1--04506_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. 11.1117111
1.Wen C.daaeter Information:
GARRO' 1-1- 14 ^-3 2• S
well Contractor name FROM To nalys�isoir
4- 5 t cl A 2.c�n. A, 5" . ( - , car- — C 5 c -Y-,
ft. ft
NC Weil Contractor Number
( k)ecn 'LcN-lcA w c I ( far 1 t h C \nC PIWI4 0 I"' Iems �L .
Cry Name A J i O a I ir d7¢ • a s, l/t. , �'. '•
Z.Well Construction Permit* a D 4' - ro c. t 5 ) ISOM To DUitti= tfficineffis _ erATInuL
List all appNeabk Well ooamrdloupw,woor(Lee.(TIC Cavity,Stets.Katmai,arc) ft. ft >d
3.Well Use(check well ease): ft' ft. — I'. —•
Water Supply Wee •.
Saone TO DisKri A SLOT era Tffi(YNC86 MAMMAL
■ DMms eiparnttblic ft ft. to
■ -.... ... (HenteglCooling Supply) QReaidotial Water Supply(single) It. ft. he.
■ DRtxidential Water Supply(shared)
11011 TO anwhot AI., n1P A®@ T METHOD•AMOUNT
Na-water S.pply Wan ' O 'p c) "t 4 y oq!tt 0, .r63 e 5o lb.
■Monitoring DRecovery eft !t Q 6`yam e!�
Injection pWe�n:.�� ��y y� ft ft " e 6•�
■ .."eM1 Recharge IDOrou dwat i Remedistio l
I •.'I,. Storage and Recovy ['Salinity Barrier pleoM TO MA7[U1AL EMR.AIMMINTMinion
■ ..•,.. Teat CISDormwat r Drainage tt ft
II r ..A....• Technology ['Subsidence Control ft tt
■ (cloned Loop) arraeer
PROM TO Dr liMPTI i4(des radars.sahaek., vole alas.die.)
■ e.• .,•• (Haa>iitg<CaoihtgBamtton) d (explain tinder 1121 Remade) 0 ft. 1 (") B. , 13,0 rk-d-C-��r`�
( pya 4 Ca Data wen(a)Completed: Well IDit {0 g �� ;�I�yD� /�'-�'�hc.r���,
5a.well Lomas: a b oft b7 \XP111 A� — -�-. inn
Pere n�. ,A• s SE Y-' b -1 O -v- -...:� �� �
tar. s �- ,•., r 1 _
pc7lit�onraaxme 1�Mil Of applicable) to !� ;...+.o tl_. V � ,
s$-t s1 c gh .r74tR Vc ) t
Physical Address,Crsty,aedrp 1 SUC far. ft. ►I t 1
Canny Parcel IdeaCnatlm No.(PIN)
-
sb.Lalttade and vaghtade in degeeeit dantedsso.aa or dedttaal dames: —
(dwell field,one be/longs stack*N �� ( � e� � W tZ tlt� ,Ceroa: ' � c
6.Is(are)the wen(.�ermuest or D'Tmperary
Sigma= Well Coatracece
By giligatil this J6rs.I hereby cast&that the wellO)war*(were)cnett need bar
7.1s ads a repair to an taL4hg wen: QYes or DNo with IS4 NCAC 02C.0100 or ISe ACAC 02C.0200 Well Co,utnasbw Standards and that a
f thv is a repair,Jill out bows well ooeune.alaw moon sotiow add a pia&the nature tithe coPy of tide'word hat bow provident to the well o+.wer_
,epadr wider C21'eeaeatitr season w an the back of this fares 23.Site diagram or additional well details:
&For Geoprob&D17 at C7aned-Loop Geotharond Wean having the same Yon nnyr use the backof this pie to provide additional well site details or well
caeotudion.only 1 t3W-1 is needed- Indicate TOTAL NUMBER of wells construction details. Yon may also attach additimnl pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total e,vtH duple below lead asorfsee: `--1 (1) 24a.Fes"Al Wdb: Submit thin form within 30 days of completion of well
For medHple wells Net all algae ifd (example-30lj200'and 201001 construction to the following:
10.San&water level below tap of agog: a (IL) Division of Water Rewmreea,Information Proms Unit,
4 ae level is above wedgy sae"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
IL Boreieie diameter: CO (6t)4
24b.For Intention Wag: In addition to sending the form to the address in 24a
12 Wear eoeateaetiw method l`o��"r m• above,also submit e copy of this form within 30 days of completion of well
construction to the fallowing:
(ie.auger,rotary.able,direct path,ale)
Division of Water Resources,Undergzoaad Injection Control Program,
FOR WATER SUPPLY WENS ONLY: (7 1636 Mail Service Center,Raleigh,NC 27t�i19-1636
13a.Yield(ipaa) -- • Method act'aeon `` - Qs. 24c.For Water Stmoiv&Inl,:(on Welk: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.DLddestlaa type: 1.4114 Amman t 5 83 Z - completion of well construction to the county health department of the(-randy
whore constructed.
Farm GW-1 North Carolina Depatmeet of Environmental Quality-Division of Water Room eta Revised 2-22-2016