GW1--05757_Well Construction - GW1_20240926

1t I i I t tl\s 1 t:l t l RIt\ lip i tt121t 0,11 1) l.„ lot.,,,,1 l' ,,I
t.,,,.,...,,;...
i
jlimit I,I In•:I In 11'II+,'F J
;t, . A Lso 1, 53) tr 1
itfTn tl.to I. 11/4
- -
IC t)lIf F11 l'tsi Vl:tr„r mniM<v a 1JSf&u+R �rIlleit tile -,!,1., 1
\ \t 'Litt ' \fit' ,hilt'• 1s1imp pat IRunt _ 10 In.l+etrsa .s
I. I R � Li 7 . I..' ; rr/r>as F t Y t (-), , --_
/ r 16.tr4!-tt t tMlvc OR I IIII:ti(,wdherm 1 rt,r..1 bay)
\\ell t.,n,.l,i,.ttont l'etim(4. C'- ./ ) ( 'f FROM ----T II)___._-._ fill%lfI IFP ..I Ifttt,k'my{ -- yt.,.,,t 11
R. R. In.
‘1 ell t St'talCek well WO: R. R. or. i
- - - i',.SCRII'.Wirer Simply N rile _-. __'
I Itnit 10 I)IA111'1 F:R II.r,F'o1/F. 1111'IL'•1':- .t,i'..,1.. ,
1\hnucipnl llllllic IL R. in.
,',y...,.S.', ,L t sdcntinl\Water Suppis(single) rt. rt. In. -
❑Rcshi`nhal Water Supply(sh:try i) Is.r.Rot,r --- '
❑\Wells-1410.000 GP1) �ROat ' r0 , .N1,11FRIA!. [ eMriAL-F-MKs,t ur.nto n+k Ow,t,•,7 ,
\07-\1 tF S
.' ,1pph \\c:1: OIL Ord IL , 4 Cfa1.1 prti,i'
°Recovery' ft n.
Inlect:o IN ell•
R R
R chargc ❑Ground.water Rcmcdiat''n
19.SAND/GRAVELP-tt't..nr appltcante) 1
.-S:.xagc and R.co\a} °Salinity dttrrcr FROM ( CO SIA I F.RIAI. EMPL\CF:MF:`,r SIEIHOrI
T.:S.t ❑Stotmwater Drainage R. n •
-
_ ::.-aal Technology °Subside:nce Control n. ft.
lip.;::::Taal(Closed Loop) ❑Traaco- 20.DRILLING LOG(Attach aadluonnt clarets It necessary)
i I rRO( TO DESCRIPTION(color,turnnece millroek hp..polo Ore.etc
_i: '`)c'rma;(lieatir 2 Coding Re um LOth, lexpinin under'_l Remarks) O rt. It ! �t\
4.R.ite\,d cl(s)Completed: /04-$" 3_ 11 ell 11):: as ft 3 S- ft. e rekt, -/
,.a.Well Location: 3 s- IL TO 5 R' C rc,t'1'Ci _,.
vak t•1?1 43 wee >� ' rt. ft. AIL.. , 1 �.,
.... :- '_.,71cr?:a.::e racitty DI(if
applicable) it re. SEP 2 0 2624
2
J t (0 S C. �4'. �.lc p_ o+" }`,`C R R I
1ref`:�7�J't ..- +
"aiA,1'•-,,rgr
i `,C 21.REMARKS
_- - Parcel Identification No.(PIN) Used steel hardened drive shoe I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I,
. -:_.1 csc la:I.r.g it sultictent) 22.Certification:
3(9 . oS915 - N -78.s19146 W 1,k-Fs-oN....
Signal a of r' ,. cll Contra 1 D).e
6.Isfare)the weu(s): LPerinent or °Temporary tn --
By signing tins form.I hereby ce ,Jj•that the well(,)was(weret constructru rn..crrdaente wren
7.Is this a repair to an existing well: ❑Ycs or ONO 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction.St oral.r,4s.are,t`ut;: ,.
:�s it a repot,.fill out known well construction information and erplan the nature of the of i/as record has been pro,aded to the well cure,-.
repo:,ender.21 remarks section or on the back of this form.
23.Site diagram or additional well details:
Y..For GeoprobtJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Nell cxuast.eI:,1n cr;,•
alas:roc:its.tar;}'1 Gu'-I is needed. Indicate TOTAL NUMBER of 1te11s (add'See Over'in Remarks Box) You may also attach additional page:IC 5e.e .try
fir.11 . 24.SUBVi1TTAI.INSTIWCTIONs
9.l utal well depth below land surface: Sa-0" (ft.)
Submit thLs G\V-1 within 30 days of well completion per the relloNsme.:
1.-.,awlt:pie.ell:hat all depth,tfdtflere.0(example-3(g200'and 2n1IXP)
24a. For All Wells: Original form to Division of\late R..i,n.,,, .'Y:,':
!u.Static water lesel below top of cluing: 1I O (ft') Information Processing Unit,1617 MSC',Raleigh.NC 2'n9,1-Ie,I'
t..o:er te.e!c a1.,i.e camg u:e
n 24b 1.For In ection Wells: to D\1'R, llad T ound In ylu n t'..::a., t'`
11.Roo thole dlarrt-ter: 6 (int.) Copy }`
Program,1636 MSC,Raleigh,NC 27o99-1.63n
12.Well Iorntruttiuumethod:Rotary 24e.For Water Supply anti Open-1.0op(ro,theniul Return\\eil. ,
, ;.z,r ',Lai.,...;,:,:..i«,-,l.._l. c,..1 county enviroutuental IIo:illh ih-puarancnt of the..,unis ah.1t aiv t`.ia:
Ff)ie WA'1 Lie SI:1.11.Y Wh:LI.S UNI.Y: 24d.For\Voter Wells tuduihii er_ltA1�FM1ti Gt'pl.t'o11\ a,1 mA:: .t'\ .
I/a. F kid Wart, Blow Penult Program. 1611\Ise Raleigh,``t'"1')`Li.,.i
art, Method of test: _
13b.Ilislul'cctlou type:HTH Artwuld:
Fumy ti'Ai I r'Audi t'roaluta tiywamicut anion,. incnlut+tu.da) 1u 1>a:01 uI N'ate1 11 4...,Ail*, .<s......, , .,