GW1--05305_Well Construction - GW1_20240906

t
CONSTRUCTION RECORD•(GW-1) For Internal Use Only: ice*
v,<`:Contractor Information:
.. s:ocher Greene 77---- �--- - - 7.� ;=< % -.. ..,:- ..
FROM -PT __J�O �DESCRIPTIO\
ft.
2 .3 5-.A
—
ft. ft.
.. .t....,oa:t.• O^Number
'VE__ DRILLING, AND PUMP SERVICE INC FROv TO DLAMETER TFEICK\ESS VATER?At.
ft.a In-
1 / l
_.- :. cz'Construction JW1 V UL 4- ' Ij FRO't TO Dt&\rE. THICK.\T.SS N.ATERiAL
_.... ....,,,rsn•rrctior.rxrmie t.s l;.e. 'lC.County. (; ft in.
State.Variance.rtc.i I
... , c.,check well use): ;. ft. n.
i
L -7-
FROM TO DIAMETER SLOT S:7_E THICKNESS y a"ERIAL
DMunicipa'l/Public ft. ft. in.
'" ... . .-- . ...a::ng Cooling Supply) Residential Water Supply(single) ft. ft. In.
..ctai OResidential Water Supply(shared)
FROM : TO • \t4TER1.AL EvrPLACEMiNT METHOD&a\MOL'\'
` r._,.: tor pply Well: i ft. � wm;
ft. sax occ-ec
- V
Recovery ft. ft.
ft, ft.
-... :. lr-e DGrowtdwater Remediatior• `
?:.,,age and Recover' Salini Barrier FROM O ..'- EMPLACEMEVi METROD
tY `,FRO 1 TO ��t4TERiA:,
. .r T• • OStormwater Drainage ft. ft.
• ,.. Technology Subsidence Control ft. ft.
..,.....-Loop) DTrace Y_. _ _,`.�. ' '
iea:ingCooling Return) DOther(explain under a21 Remarks) I FROM ft, i TO ft. DFSCRTP TTO\(color.hardness saV xi ti e= :.ci x,c;;.
- :.We:i(s)Completed:8"I5-210,1 Well IDN ft. l ft.
ft. ft-
I� y ir--�i• e✓�.
ft. r
acility,iD',If epp,r2o, ft. 1- ft. SE f O 6 2024
t
2q(� Shur wood DRtve 1ti&j-d-kn I ft.
:;:,j Zit ft. ft. 40,E cteri a.r..ryos^g tJ+dl
�!��er ford I62121947 q _ _.�: .s�...4,-
Parcel Identification No.(PIN)
and longitude in degrees/minutes/seconds or decimal degrees: It
..tt:ot:g is sufnctent) 22.Certification:
N W 0;67..r�is•.„„, B-27—202 -
-. -.h, well!s)igPermanent or OTemporary ignaturc ofCerificd Wcli ContractorDa:::
By.signing this form.I hereby certifi that the well!tt was(sere/canstructrt. r
- - • - an existing well: Dyes or �No citli 15 a.i.VC:4C 0?C.0100 or NCACO2C.o2nei Well Cortstrucnon Star r. ,o,::••.
- ,r{:na:on well construction information and explain the nature nfthe• coy al this rernrdhue been provided to the Kell owner
_ „•tion nr oh the hark of this form .
23.Site diagram or additional well details:
- G io be.DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site deta or
GU-: is needed. Indicate TOTAL NUMBER of weirs construction details. You may also attach additional pages if necessary.
'one SUBMITTAL LNSTRUCTIONS
depth below land surface: 2i'�5 / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of wcli
,.rt pep:r„s:fdifferent tesomple-3(4200-and 2^a`1001 construction to the following:
..:en.water level below top of casing: 14LJ (ft.) Division of Water Resources,Information Processing Unit.
rstng.sr _ 1617 Mail Service Center,Raleigh,NC 27699-1617
e diameter: 6 1/4 (in.)
24b.For Iniecd9a Wells: In addition to sending the form to the address :r.:-;.
Rotary above, also submit one copy of this form within 30 days of complex.. of.;e,.
...construction method: construction to the following:
. _. ..,...,...tree:push.inc.)
Division of Water Resources,Underground Injection Control Program.
• --sTER SC-?PLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
torn--; 15 g(m Method of test: Air Blow 24c. For Water SuDOty& Injection Wells: In addition to sending:ne form:e
the addresses) above, also submit one copy of this form within 30 days of
,'.-'::^or 7NPe: Chlorine
Amount: 367 completion of well construction to the county health department o:r
where constricted.
North Carolina Department of Environmental Qualm-Division of Water Resources Rev:sea'-'__-'•: