GW1--04623_Well Construction - GW1_20240809

r`—'�(ONS'1RUCTION RECORD (GW 1) For Internal Use Only:
1.Wtt11 Contractor information:
_V rl�t S Cyr rr^ 1 wArui Pf ,--
Well r Vt IC1SC�� MOM , 19 nes Rrrftor
Contrite-tor Name
I
NC Well Contractor Certification Number 3 t_,n 4 arc* n. _ tt 0`1C�
14.(nnitII CA$iNC,i stir" ,�,l, c>
iaoM to �--nrAMr'rt(a tRrcKnrae �urzMAI.
s t.>�a a ,I -J
ft. n. In.
('ompano Nrune
J
,lii C S1 NO en 13I*INO famalarira f d embsa l2
2.Well('onstructlon Permit q: .1-C.►-j - 01 i L-) IRON to DIAMETER , rnK1mm _MAT r,
1
.131 all appli,nhle wrtl canxtinr nan pennrre ft r 1:rr' , .•iron••,Slnle.Vann.re rlr) r) n. „- U n. (O �X la. Ky t)( 71 `
3.Well I'se(check well use): n. ft. `1 hi.
I� '
't%ater Supply Well: U.tiCRRlIM
MUM iV . DMMI17/t sun.tun, 111k Kamm c,sEst[aul,
❑Agricultural ❑Mtmicipat/Public n. is. he.
❑Cieothcnnnl(1leatirtg/Ccwsitelg Supply) nl(c,rt{enual Water supply(single) n. n. in. { ,
Dlndustr,al'C'ornmercial ftlieesidcntinl Wade,Supply(shared) iLCROVr —
_nlmgatton raosi To NAJEtaiAL EMMM.a rMPrrSOT1N00!_aNO('NT
Non-VI*ter Supply Well: 6 n. ,7c'S n. 6el'Pi1'1. t i-G'i-e.
,-Mon itcsnnp ❑Recover n. ft.
Injection Well: - �ANI
n. n.
JAquifer Recharge ❑(iroundwater Remedintion -
d uitet Storage and RecoveryIS.SAND/GRAVE1,PACK(Ifaetalipile)
Aq R OSalinity Barrier FROM to I MA fj:RIAI. ! EMfl.A(EMF_rr SIT runo 1
JAgmtcr Teat ❑Stomtwatcr Ihainage n. n. ii
DExperimental Technology ❑Subsidence Control n• n. 1 _ J
J('aaothcnnal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach add)adaalahee(a if aaemery)
M'R(1M 1 "IDFaCRD'rl0t (core.hardaew,,esirerY bee,Erato der,ete.t
0-Geothermal(Heating/Cooling Return) ❑(hher(explain under u21 Remarks) n. n. Leyy/C �b-�
c (f t.r
dt
4.[late Well(s)Completed: -7- i� t Well EN -I, n' 1 i 0 n' a.(C14tA1--€
Sa.%1 oil i:ocadoa n. n.:
Zoe . Ar.gd, cod tick n r_ ft.
4,.... ' 'i,�- )
Facthn(h.ilea Name J Facility IDk(if applicable) n R.
Lot l _ILA;c. Viet.) Ha ' ,NG otS/s1 ft n �1 ?G7' ,
44ir Ibj lr�
Physical Address.Oh,and Zip J7 It.
Baca 7'i87-Dtin, ^3S10 2LREMaxxs )
County Parcel Identification Nu (PIN) — 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one latlong is sufficient) 22.Certification:
v
,SSa 3 ; is 3 .s z�N g,,S6 to r t 23(aL83 w e__--_, :_-.) ----= -
igaatare of Certified Well Contractor Date
6.'stare)the well(s): el-manent or ❑Temporary
� By signing this form•1 hereby cenrfy that the went's)was(went)constructed in accordance
7. IS this a repair to an existing well: ❑Yes or t�IrO with 1 SA NCAC 02C.0100 or 1 S and A NCAC 02C.0200 Well Construction StandardLs d:h o
It this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under=21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details You may also attach additional pages if necessary
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled SUBMITTAL INSTRUCTI( 5
9.Total well depth below land surface: -1 1 t) (fl.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths if different(example-3@200'and 2@1a 100) construction to the following:
10.Static water level below top of casing: 1 cf' (ft) Division of Water Resources,Information Processing t nit,
If water level Is above casing,use 1617 Mail Sen•ice Center,Raleigh,NC 27699-161'
11.Borehole diameter: CC , ��'' (in.) 24b.For Injection Wells: In addition to sending the fonn to the address In 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1Z°t-CI CI construction to the following:
(i c auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ',,,, ( r' 24c.For Water Sun & !l 'ectlon Wells: In addition to sending the form t
Melbod of test: iLt( r Cat� ➢ U' N
the address(es) above, also submit one copy of this form within 30 days
13b.Disinfection type: Q(rNibv\Y'C Amount: 1 b'z - completion of well construction to the county health department of the coon'
where constructed.
l` (i�1' 1 North Carolina Department of Environmental Quality-ll,visioa of Water Resources RCS1SOI 2-22.2(