GW1--04786_Well Construction - GW1_20240814

(WELL CONSTRUCTION RECORD(GW-1) For Use may: i_- 1+: +v�.t�
• 1.Well Contractor Worm:1Nsen
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Well Name
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NC Well Cogmaetoc Catifiwtice 23aeloet
MOti l�ilE� veil VIA Al YsOUTER Caau1c 1..re�rmils)OaLOOMtk ).
Company Name 1 f �'R- riELCIOMO nAT>cot ^2 Well Co oetiaet Pvwit ik C✓\k V - IQ lent pilau it Lio3
ro l.tAIMEga"'>r"/
List al a}rlicabk well consenrctionpe nits(Le.WC Crimes Siesta Faetaseie am) - R R. i e. �
3.Well Use(check well use): R A it..
water Sopplr W scat>sus
}Agricultural h tiapeyl'abl'ic 1 TOCOMET:u: L ft.
© �(ll 1Coo�Supply) Residential Rater Supply(single) rt. a. Ia —
, f IDdusteig,reen eeciid Rosiaemig WaterSiepply(shared)
Pion- 'itr3f�7p�yWdk 0 Iteo,� : imin -- �]��� c METHOD�l.LMWUNT
,J)Monitcring DRecove y It.
(SJ R ff yjt ' L1.Q
Injection Well:
tAquifer Recharge OGroundwaterRaeoSation lc r<
�}4quifa Storage and R w.v} QSa}inity Barrier 'a sa e:RA1 PaC rfra..sr etej-—
QAquiferTest QSOwwtretra DrainageFart t te. o R.
EVIL EMPLACEMENT Milli OD
DE merimcnsal Technology r3Subsidence coCntrl s. ft
fjGeolbennal(Closed Loop) f Traoa 24: TA44ataef add�taa_i s4st1 iifaaeian-
IGeofltemal(HealinavCoofingRemo Other(<9slain melee:t:21 Remarks) ft. TOft. '?Pr' �"ti1vte Fate slat eta)
4.Date W-^3(3)Completed: . J 4 si�.L 1t : 7 R �t, l(l' /�
Sa.pil l�D� 51} R t/OWW\ 0 dy.
C AA" i c A j 1 " li a• Glom.i 4 t
FecilitylOecttct Yaatc fecalay 1l (� abk) ft. ft..,
jhr►;iq� ( it. la.- /t,
Physical Address.City,and zip (1 tt ft t In1
I_ (\4°ln zl sti3r.er� . .L 4 �t'
Camay Parcel Ice.fiotiac No.(PIN)
5h.Latitude and longttade In degresiminuta/setends or decimal degrees •,
al well field,coy latlbq is sufficient) '
,55.v5&51 N �f- 3 11g W ��. )„ li
6,Is(ate)the wells) Permanent or ©Temporary Signature f - Well Contractor Date
ay_aping thfs form I hereby certiif Om the waifs)war(were)cautntcted in accordance
7.la this a repair to an existing well: D Yes or 13No with 254 NCAC 02C.0100 or 1.54 NC4C 02C.a?o0 Well Cautroction Stardardr and Ikea a
fiats is a repair,fill out krmm well mrtstrctket iritorteottoa and erpktfn the nacre of the C'FY°•th s rrcrrd hat been podded to the well Omer.
repair under 421reatar",a soaks,orat the bock ofthis Ans.
23.Site diagram or additional well detain:
You may use the back of thispare to provide additional Hall site details or tall
R.For Geoprobe/DPT or Closed-Loop Geothermal Weis having the same
construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of arils construction details. You may also attach additional pages ifneme try.
drilled: SUBMITTAL.INSTRUCTIONS
9.Total will depth below land surface: ` (ft-) 24a,for All Welly. Submit this form within 30 days of even
For multiple wells list oil depths tfefffertnt*ample-
OO end
@JgOI completion of�1L•11
construction to the folbtving:
10.Static water level below top of ca (R.) Dhisirort of Water Resources,Infor m:4bn Processing Unit,
If water level is otiose=Mg rue-+w 1f17 Mail Service fir,I a1
11.Borehole diameter:_ (9 / Cut.)
`�� Q 2<tbt for fake*,Weis: In addition ro sending the form to the address in 24a
12.Wei construction _ �,S�( ahwr,also sabred one copy of this form within 30 days of completion of l
(Le.eusn rotary,able,direct push etc) gat
Jj eanshwetin,to the foTiarittg
Ditision of Water Resources,UUwde galas d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mal Bemire Center,Raleigh,NC 27699-1636
13i view(gm) C Z It srteest T A)�-r 1-144 24e.For Water r,k filiation Zlrejls: $addition to sending the fonn to
/1 S the address(es)above,also submit one copy of this farm within 30 days of
13b Di�fectiowtype: Oiler/4AmountL 1 of well arrssatine»c to the toasty health department of the county