GW1--05008_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD(GW-I) For Interna Use n1y;
I.Well Contractor 1 formatiJ - ct
"A
G1
G U{� — FROM TO DESCRIPTION "
Well Contractor No - ft. ft.
/ 4 3 A ft. ft.] •
NC ell Contractor Corti lcatlon Number 1'S,;oGT )Z CA sINQ:(tgr.rw►fti�ee6U:wti)It)UILLINEII`(d.flp llc'+ltile)
�/ ) jam FROM ( TO DIAMETER
� TIUCKNES4 Mole) .AI,
L y� (/)/�1 Pv_ilkp �!} / ,1 r ! fL I gG, fl, �t�, i o�.n' DR,2I P YC,
CompanyNema I h 23 q 4- 3 :•f6iJiNNE1RJJJC*gIN:d weals 'lO,'.ttieothertt/I)S1b s4 19DP)• • • :; .
/ FROM TO DIAMETER TIIICKNFSS MATERIAL
2.Well Construction Permit#: ft. ft. lu.
List all applicable well construction pe,mils(Le.UIC,County,Stale,Variance,etc.) In
ft. ft.
3.Well Use(check well use): fgt•$C +t Iv' • •;,. • ;;:
Water Supply Well: FROM TO DIAMETER SLOT SIZE•. -THICKNESS MATERIAL
Agrlculturel
MunlolpaVPubllo ft. it In.
Residential Water Supply(single) 'ft. ft. lo,
Geothermal(Heating/Cooling Supply) �
lndustrial/Commerclal DRosidontial Water Supply(shared) dei.glt0
FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
Han 0 ft, ft. -ery �G "� _ 1 G
Non-Water Supply Well: ft. ft.
[Recovery
Injection Well: ft, ft.
OAquifer Recharge Groundwater Remediatlon •
Q )7 S}CND/(iRAVEi.'PACI MATERIAL�Aqulfer Storage and Recovery � y ft, tr.
0Aquifer Test DStormwater Drainage •
Experimental Technology ,,•
gubaidenoe Control ft' ft.
Geothermal(Closed Loop) '+ [Tracer 7,O;:DR1ft. ,O LQG(aftt adtllHo0bl, he,0tg11llttectdestY):.'
FROM TO DESCRIPTION(color,herdow,iolVrock type,grain atm,etc.)
0 Geothermal(Heating/CoolingReturn) MOther(explain under#21 Remarks) ft'
/ja
✓ ft. t G/, �
G)D ft. �� ft. _. _I I _ '
4.Date Well(s)Completed: g ) oL Well ID# GG ft ft
5a.W ll Location: `` ft. ft.
('Ln _brit, PJn ft. ft.
Facility/Owner Nark, Facility IOU(if applicable)
ft. ft.
. -3 5—Tl,t�-y 1) I ft. ft.
Physical dress,City,and Zip N
'l '21.,I�tt1i1R� •.
V (PIN)_ •
Parcel Identification No.(
County ,
5b,Latitude and longitude iD degrees/minutes/seconds or decimal degrees: 22.Certification:
field,one let/tong Is sufficient)
PA- , ;6 3q'7 N I, 6 .9 '13 W - . o A. c'
diQnaturo of Cc; ,ad W:!;t:ontsaota
Date
6.Is(are)the well(s)SPermanent or OTemporary By signing this'faint,I hereby certify that the well(s)was(were)constructed in accordar
with!SA NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and the
7.Is this a repair to an existing well well: Yee or �NP copy of this record has been provided to the well owner.
((this is a repair,fill out btuwm well:
information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may uso the back of this
T or Closoil-Loop Geothermal
lls having
e
construction,ronl 1 OW-1 is needed. Indicate TOTAL oNUMBER of wells
same
to provide
ional
8.For wells
construction details, You may also oattach additional tpages If wellnecessary.sitells or w
drilled; SUBMITTAL INSTR[)STL2L'l�
9,Total well depth below land surface: - _--(R') 24a. ESr II Wells: Submit tbis form within 30 days of completion of µ
For multiple wells list all depths ifdif'erent(example-3@200'and 2@l00') construction to the following:
1 (L _(ft,) Division of Water Resources,Information Processing Unit,
ll Static water level below top of casing: 1617 Mall Service Center,Raleigh,NC 27699-1617
(/u•werlehole diametabove er:
sing,use"t" 1
/� in.) 24b.ForFor Inl&�rcJ: In addition to sending the form to the address in
11,Borehole diameter: above,also submit one copy of this form within 30 days of completion of v
Q a . construction to tho following:
12.Well construction method:
(Le,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Infection Control Program,
• 1636 Mall Service Contor,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: ( .
Q Method of test: a__r--__ 24c.Far Wa_ I_ or IILDRI" '' Infertionoll30W .v: in odi addition to sending
the days
13a.Yield(gpm) the addresses) above,. also submit one copy
ll completion of well construction to the county health department of the cot
13Y.Dlsinfcctioa typo: lyY Amount: where constucted.
•Division of Water Resources
Revised 2.224