GW1--04683_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only; _
1, ell Contractor Information;C4rre y I fG dJki _ _ - - 0 ore) / '%Bu urarei r7, n
Well Contractor Name ca st D
I N
•
ft' re.
L19� 5A ,
NC1Well Contractor Certification Number ;+! iQjjj�l;((i )jy c]({'{)Ati" f it MOWti ..;..4,�i °�I�A'S�" 1+
ff//1''��� ��nn� {I d 1��1 Co, I T3 E' ��+r��u/�c���it ;41V
l.(t)1� S Vi e�� CUl1 I v � l� �O� T� lim...
ri./ In, �l�■Ti7>�
IIIIII
CompanyNamo ?, .'iZillilLG7 1?ArL4Kai.u?ji illFMlltinit)IiNtOM�1'
�y /�j G � MATERIAL
1INIMIlla
7'1 v0 (] ifOu TO M• E;
LlWelConaeu!c Permiot bt ft, ft, In,
List all applicable well construction permits(he,UlC,County,Stale,Variance,rrc� It, R In,
3,Well Use(check well use); I1r•.t•'<J•..•J°J1,ieliSrAkii 7aa£.k.,7' A IIIMMIMEN
Water Supply Well; ;t;0u 0 DI, 81.0 8 Z THICKNESS
0Agrloultural e.. Munlolpal/Publlo rt. ft, In,
�--1IY — In
Deothormal(Heating/Cooling Supply) DRosidentlal Water Supply(single) ft, ft,Industrial/CommercialQRosldontial Water Supply(shared) -fl"jcom£ `S''.'' mosgE"gianwatignigi
,
FROM TO . ERTAL EMPLACEMEN�'TNOD&AMOUNT
""�Irrigatlon R, �����. b i
Non-Water Supply Well: ft, tt,
Monitoring [ Reoovory —
Infection Well: ft, ft.
Aquifer Recharge ©t3roundwaterRemedlatlon 9h ;�y y1ie h ip" ':• ` y}`',„t; +'r2'• `:' r•: ;
Aquifer Storage and Reoovory. Salinity Barrier
0 0 a• :RI L EMPLACEMENT ETHOD
ft„
ft,
Aquifer Test ) �StormwatorDrainage
ft, ft,gy `&• OSubsldonoo Control •
JExperimentalTechnolo v l to !rf ;; ';:% r,;( .,.c,.
Tracer f�Ag T a ?� s isD i
-
Geothermal(Closed Loop) � PROM TO Dv:BCRIPTION color herdnen colt/rock r rein size ric.
Geothermal(Heating/Cooling Rotum) �Othor(explain under#21 Remarks) O ft, 0 ft, a
4,Date Well(s)CothEiletediV i 7 0�y Well ID# 7 illariniA
5a,Well Location; •
ft, ft.
ft. •• --
Pnolllty/Owner Name Facility lDN(If applicable) ._--- ----r-4
l L ft, fL
1 rot vi i ht. g I , ,ft ft, — 3r C .� it-
1e.vela�►d
P alcal Addro,e,City,end Zip y ,)�Lft y+ Watd r.IF `)
_
County
Parcel identification No,(PIN) _'s
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi; 22 Certification:
(If well Ileld,ono lot/long Is auf(lolent)
C.jA2620 N :-IL63RGO W ' - b — D Dale
2
Ignatureof:Qertitled W II Convoy! �
6.Is(are the well(a) Permanent dr Temporary
By signing this join+, /hereby cerl(ly that the wells)was(were)constructed In accordance
Weil
CaislJ'u.b.'•"'endards and that n
with 11A NCAC 02C A/00 a'1JA NCAC Gi C,D2 O
7.Is this a repair to an existing well: �,'Yes or �No co y ofdds record has been provided to the well owner,
(jlhfs Is a repair,fill our knotm well oojtsrructlon ht/brmatlon and explain the nature ojthe 23 Site diagram or additional well details:
repair under h21 remai'ks;tctlan or on the back gf/lls joint,
You may use the bank of This pogo to provide additional well site details or well
c8 For Geoprobe/DPT O or Is needed,
Didlo to TOT Wells NUMBER of
same construction details. You may also attach additional pages If necessary,
consiruotlon,only l OW-1 needed, lhdloafe TOTAL NUMBER of walla °TJBMITTAL INSTRUt;,T'ION3
drliicd;
9,Total well depth below land Arent el
r 6 J r A(ft,) 24a, Foll Wellat Submit this form within 30 days of completion of well
For multiple wells Pot all depths((di/Arent(example.3@200'and 2@IOO' eonstruotlo following:
(�O (ft.) Division of Water Resources,Information Processing Unit,
1
(f ferle waterabove level below top of casing: 1617 Mall Service Center,Raleigh,NC 27699.1617
Uwnter level Is casing,use"+" ad
(in.) 24b.For IniecHon We1l;Stln addition to endin 30 days f cope atdlon elf
n 24a
withi
12,Well construction method' well
11,Borehole diameter; above, also submit ono 0op y of this form
-10v
construction
construction to the following:
(I.o,auger,rotary,cable,direct push,oto.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mail Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY; 24c, �„ , ,nnN&Inlectlon Welis1 In addition to sanding the form to
r p
13a,Yield(gpm) �O Method of test: —' the address(es) above, also submit ono copy of this form within 30 days of
G/1 I UY i Amount; L v -- completion of wall construction to the county health department of the county
1b,Disinfection typo: whero constructed,
Revised 2.22.20I(
North Carolina Department of 9nvlronmentai Quality•Division of Water Resources
FormOWI