GW1--05704_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW4) for Internal Use Only: 1
1,Well :tractor Informatto /n/ - ,
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Well ConlreolorNemo/ R; (6 I,
1( s�4 - ft. ft, C`,
NCWoI ConheotorCenllloetlonNumbor • •
:.ilo'" •r qtV )'r��T."•"''.Il el�( 1,."' _1'�.;'t MN.,,'i' 1''1`i •;'.'
�l�m • q DI,'tiTER n. THICKNESS MATERIAL
C'C is �oM rt, TO rt, f.Z-51. 1� I ' V G
Company Nome ' YlfI i�ia.i7,T1.i1C�iVolV.u?isSi.UA(d`f,lat�(:1 IT)1:: `�Tll'xf'9'fi
/f 6- PROM TO �jQMETED n, T ID BOB MATERIAL
OIMISMUNIN
Z,Well Construction Permit Ns ! l r rt. tt� •
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Gist all applicable well conatructlon permhs(h�.UIC,County,Slate;Variance,eloj • i In,
. 3.WellUse(checkwelluse): r�i:. •1.:. ?t'11�`''b .Q.'i1�,tI j ! �,�Y ?: iyyl t.ii:.rf.�" 7:�1 f.,i.'� i
Water Supply Wells • FROM TO DIA %TER aLOTSIZE TH1 $NEBB MATERIAL
LnAgrioultural [ Munlolpal/Pubno ft, U. 1, In.
• 13Ooothomal(HoatinglCooling Supply) gRosIdontial Water Supply(single) ft, ft, '- - r .in, . •
)llEiInduatdallCommerand DRosidentlal Water Supply(shared) a l;`tod• off;, 7 i^, mag'dlK(mi me i'' my' A:••.: ,r
FRO TO
MATERIALEMPLACEMENT METHOD&AMOUNT
IrrlRatlte • D ft, O ft, iydr j t ,/z.6 4$-P D t{.r e
Non•War Supply Wells • ft, tt.,
:Monitoring , • Rcobvory -
• Injection Weill ft, ft, •
A ulfor Roohargo �aroundwaterRemedlatlon pd w,. .g yp"•d ,it .,1 f$tarr �,�_;li: 311 ;)f.0),.:;ti:•a::.,••:AM: .• ''•1
3q EMPLACEMENT METHOD
Aqulfer Storage and Recovery' '` ` DSalinity Barrier . Litwin To M •MAL
(t� ft,
AqulferTeal . %.-; • �StormwaterDrainage
•s�'t s ' Subeldonoo Control it. it,
Experimental Technology rti,,�• • � r . �._•�"'',•�••'
Oeothermel(Closed Loop) `'' OTraoer o�'�bff'!L`To Xsltt c2l s E i CRrt Ti•N oo�r,hard ,io ►c ee,¢rain elxe.'eloJ
0Oeothemal(Heeling/Cooling Return) InOthor(explain under 621 Remarks) ft, 4.g S. lilt.fI f ci-y
•
4,Date Well(s)Cattlr�loteds
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Wen IDa 5 2 n. /6 `61. f:rr�i 7 '
5a,Well focafont t ft. ft, • "' ' '
Poolllty/OwnerNeme •
Q q�' r acuity 1DH(Ifopplloable) ' SP 2 �2�
r ram ri e!� 1 p 'ft. It,, i'
mD r, l7ESSe1Mt.t'' R. ft. 1 ,£
Phyelool Ad rots,Chy and Zip CI fy i°i 7``.t�'i��+?: �;li,:i;,-..-', 71s,-,c .:ai+t...�r s
1 ptIl�l'A� $vti4�13� e i' 5,:d i,}
County Parcel IdontliloslIon NO,(PIN)m.•s
5b.Latitude and longitude In degrees/minutes/a:monde or decimal degreesi% 22,Certification!(If well field cno lot/long Is sufllolont)
•3 3b 7/2 N. b—g1F A "6 W 1
Gi/ �2U1, r Palo
. Signs ro of�artined Well Cont or
g
6,Is(are)the wells) permanent` Sr � 'emporary
BJ's/string this Jbr'rrr,I hereby aer,''t(ry that the well(o)was(Were)constructed In accordance
7.Is this a repair to an existing well; Yes or 19No With/JA.NCAC 020.0100 or OA NCAC 02C.0200 Well Coneruelioa Standards and That a
Phis Is a repair,/Nl out known well consirnotlon hi/brmatlat and explain the nature of the copy of this record has been provided to the wilt owner,
repair under II11 alifeirkiJeuilon or on the back of IN:Awn. Z3.Site diagram or additional well details;
' . ' You may use the bank of this page to provide additional well alto details or well
8,For Geopro only
O or Close dad.lI dlca h�rtnal Wells having the same constntotlon details, You may also attach additional pages 1f necessary.
consltuotlon,only I OW1 Is:Medea. %di af'TOTAL NUMBER of wells drilled: _,
9.Total well depth below land But'faoar "I'""'AI,INSTR CTIONS .
L 5 ( S Bff.) 24a, For All•Weller Submit this tbrm within 30 days of completion of well
_ Per+mdllple wells Sat all depths(fd(brent(eiranrpla•S@20o and J®100') ' construction to the following;
10.Static water level below top of caging; --• (it,) • Divldlon of Water Resources,Information Processing Unit,
((water level is above aaiing,use"+" 1617 Mall Service Center,Raleigh,NC 2769.9.1617
24b.Fontead n Wenz{
os In addition to sending the form to the address-In 24a
U.Borehole dlamotert � (in') r iabovo,'also submit one copy`of this form within 30 days of completion of well
12.Well construction methods �D a Y construction to the following:
(I,o,auger,rotary,cable,direct push,ate,) Division of Water Resources,Underground Injection Control Program,
1636 Mall Seri Ice Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY! �"
Mc,Yrp� aster Suaniv&inleation VVelis1 In
addition
to sendiins fonn t30he days of
to
13a,Yield(gpm) Method of tests " al r the address(es) above, also(submit one copy
( u completion of well oonstruotioi'to the county health department.of the county
13b:Dialnf�etien type; Amounts whore oonsiruoted.
• Revised 2.22.2016
North Carolina Department of Environmental Quality•Division of Water Resoiroee •
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