GW1--05389_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1:Well Contractor
Inforrmmattionl
/^ Yrr,/ct1" )1:) Vmo _ , :is? i' s. ,ir.4 ' itai'
r.I.`Wy .4.Y!.' ;''.• .. 'i•
Well Comreolor Name •
FROM TO DE WPT1ON
rt, rt,Li 5(-1 5"A rt, rt.
NC Well Conheotor Certification Number •
'4 r'o ;m, '.'olds. tEg ''L'°l 'to '�l •'_. ,n'•1'll'e'O?0,s'•
PROM DL E E' T 1 1(NESS MAT'•IAL
n e cot Pv WV U. 71.00U. C. 2, in. S�, 2 I
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YABISMINEXIM
IgC2LI_el y "ou o ' • EI HI EBB MATERIAL
2.Well Construction Permit#: rt. rt. In,
Gist all applicable well construction permits(Le.UIC,County,State,Variance,eta) rt, rt — In:
3,Well Use(check well use); , ;r. „., °J='^i':7;+:.i).r.:!'rjiC.i:'',G:r-
a'.e •-gty 11:`•'i::✓fii li A •f'? BLO B 7.E ICKNEBa AERIAL
Water Supply Wellt FROM* 'Z DIAM
r�Munloipal/Pubilo it, ft,
In,
Agricultural e..Y —in.
Geothermal(Heating/Cooling Supply) ell sldentlal Water Supply(single) ft, ft, '
Industrial/Commercial
Residential Water Supply(shared) gift v Ab?,trmct',4;4 gigui.,
FROM TO MATERIAL EMP<,ACEMENTMETHOD S&AMOUNT
Irrigationt d rt' rt' j3.0141 c r ) VV IIII3
Non--WatWater Supply Well; ., ft, it.
Monitoring QReoovory _
Injection Weill ft. ft,
Aquifer Recharge 0Groundwater Remediatlon•
4044i,1i 1. ja,ititaahtitgifirfilfl� EMPLACEMENT METHOD
Aquifer Storage and Recovery OSalinity Barrier FROM TO Mb•RIA
it. rt,AquiferTest ws" �StormwaterDrainage
Experimental Teohnology w., �Subsldenoo Control,� ,� „'A �e:e d.f �or a�4)s:;jr,tr;•r..;; ,.;,'
Traoor IalAtI1Xt'Ifjl(T{X,i . (Ptt'i�'Qlt+D 1. a
Geothermal(Closed Loop) FROM TO DESCRIPTION color hardness soh/rock .e rain sic, etc.
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 7o rL Z4a .
/�t�02•Vi Well ID# 7 J rt, 05 rt, ,7/1'1Nt-
4,Date Well(s)Col4t�letedt vaft, rt, •— .
Sa, ell Location' «, its •`'� `'1'--: .•/ t-` r
an��l ��c�lland P I e
Facility/Owner Name Feollity IDN(If applicable)
(� �+ I- /, �/ P , It. Iit.
15 5 Gh1'C.k0 / Pr. it. ,rc, a�t;t
t'hyal9ci Address,Clty,and Zip 0 11 19.0„.t':Gi ,°.,,r. '°(;ME 1
County
Parool identification No,(PIN) ••.;
_
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi•' 22,Certification:
well Held,one let/long Is suftiolont) ��
5.50Z-1 N — 31 .a6 yyY W
Dale
gigesturoof.Gertltled Wei Contractor 6,Is(ara)the Well(s))�PBTltlarient dr O'i emporary By signing this loran,/hereby oert y that the well(e)was(were)constructed In accordance
,n tent Well with ISA NCAC 02C.0/00 or i',-A,YCAC 02V ••e•I Construction Standards and that a
7,Isl is a ap lr, lr outto a n existing wells 'Yea ioo '�Ix� l copy of thls record has been provided to the well owner,
Ulhls Is a re air,Jllf knotnt well bopstruotlon hi/brmallon and explain the nature o the 23.Site diagram or additional well detallst
repair under all remark 4eFllon or on the back qflhls forth
You may use the back i this page to provide additional well site details or well
NUMBER8 of wellsa construction doteile, You may also attach additional pages If necessary,
c For G lopronl 1 O or is nClo ed needed.
•io to Geothermal Wells ng the
dopes uotlon,only 1 OW-1 la needed. Ihdloate TOTAL c�L IYllTTAL INSTRUCTLQN
drilled,
9,Total well depth below land surface; O5 --(«') 24a. For All Wellat Submit this form within 30 days of completion of well
For:nultiple wells list all depths((d(Q`arent(example-3®200'and 2®l00) construction to the following:
((G (ft.) Division of Water Resources,Information rotes.ssing Unit,
1
NC
((
If water leav water level below top of casings 1617 Mall Service Center,Raleigh,
el Is above casing,use"+"
6 (in) 24b.For Inlectlon WeI1s1I Y addition to sending
hint the
3h daysof completion address
dd ess In of 24a
11,Borehole diameters above,also submit one copy of this foptt
' -far ell
construction to the following '
1.e Well construction,cable,
methods
(I,e,auger,rotary,cable,direct push,eta.) Division of Water Resources,Underground Injection Control Program,
• 163E Mall Service Center,Raleigh,NC 27699.163E
FOR WATER SUPPLY WELLS ONLYt 24c D.Water 4uODl_y &ytle��llsl In addition to sending the form to
6 Method of leap r r
13a,Yield(gpm) the address(os) above, also submit one copy of this form within 30 days of
GU completion of well construction to the county health department of the county
13b Disinfection typal
�` Amount whore constructed,
Revised 2.22.201E
North Carolina Department of Environmental Quality•Division of Water Rosouroes
Form OWI