GW1--05886_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1./ enWill Co r Isifiroatlo•:
Well Comment Naaee To
�p g -3ft.
NC Well contractor Crtlaaatias Number
Illitfit: �,.
�AS6e it Gl1�il b1///in - 2>rc_ :,
Company Nome /7 �3• � 1 '
2.Well Castration Permit 0: j J)-#---,O/r5^ MUM nu-sa1nta T K1 sweats.
Litt od l cable weln�rt l oayction pavan(l.e.(BC County,State,Variance,sec) - R 0. is.
3.Well the(check well se): ft. ft. Is.Water Sapp Wei N. > I l
DMDmicipsJPublic 11111;1111112 to
I e-• - ..' (Heeling/Cooling Supply) identiai Water Supply(single) R 1111111 la --
■ Residential Water Supply(shared) rirr—;_r Ili ,_
■ Ti */eruption 111=11111111E'• 'r.,.••7►\ing. SASPLOOLSItttf MZTISOD&AaroQwT
Nu.-Water Strom Well: .71111 ) ft _
■ DRecovery ft. tt.
- ails
R ft.
■ Recharge Groundwater Remediation
11 Aquifer Storage and Recovery °Salinity Sorrier 1111 '' ' _.11 - .
��:� MAMMAL tiad!l.AG'thf!'IVT i :..1
■ . ifer Tau DStonnwaua Drainage ft. ft.
■Eapwimewl Technology ()Subsidence Control ft. ft.
t
■ t , •• (Closed Loop) °Tracer r � .
IR c...,. .. t+'a[MMINIS . .: . (colt,Madam,Wined um,wide ter,s1r
(l3eatang/Coohng Relent) �Othes(explain under#21 Remarks)
4.Date Welke)CNgia/sd: 9//..3/il4 Well MO ft` ft.
Sa.WellnlfLontlon: ftft.
i5 l n If t:..SO O}A�Pt- �' • • ,
Facility/0mm Name Facility DIM(if appli ie) ft. Mal t
•
'73I 8/ /} - ., _16 / ,l vco.n ft.
Miyake!Adam,City.tad Zip n f
/i/13n"-- - 42-6ctg-.3'7- IITIS 1. )I
Canny Parcel Identification No.(RN)
Sb.Latitude sad longitude In degrees/mliutes/aecondr or decimal degrees: ,
(if well add,ate latMag is au cunt) 22.Certification:
A//41 N A'�4 W /cam 9// 1, y.
6.L(are)the ws■(a)Oerifueat or 0Teaaporary Sigmaae of Well Contractor Dsoe
to on existing
signing 16f r w.I hereby cm*rhos the wells)war(Iowa)ccashucted in accordance
7.Is tole a ousting well: °Yes (TONNo with 1 SA NCAC OBC.0100 or 15A NCAC 02C.0200 Well Construction Sausdardr and that a
Otis is e repair,fill out boom well contraction tsfarwwtlon and explain the nature of the coPY of*, beat pry to the well owwrr,
repair weir 4021 rewvib sedlea or on the bock cif this form
23.She Magnus or additional wail datalls:
8.For Geoprnbe'DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL QtSTRUC ITONS
9.Total well depth Mow had arises: !,5- ( ) 24a. for AA W : Submit this form within 30 days of completion of well
For otaleIpb war MU all depths f e.'wt(aansple-3®200'and 2*100') construction to the following:
If.State wader level below top of eadag: Z')^ _(ft.) ee
) Divisive of Water Resources,Information Pressing Usk,
in water levelabove mac we"4-- '/ 1017 Mai Service Center,Raleigh,NC 27499-1617
11.>o'eb ria diameter: !j !4 (In.)f 24b.Jar lalee Wes: In addition to sending the form to the address in 24e
IL Weil aatsawetlsw method: CG,�j/P_ - above,also submit one copy of this form within 30 days of completion of well
(is.suer.rotary,cable.direct posh.es.) conftruction to following:
DlvbIse of Water Remoras,Underp dad Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MaIl Service Center,RaYtth,NC 27499-1636
13e.Yield(pans) 3 0 Method of test: ✓ __.r% _ 24e.For Wa Sonnly&laieretlgg : In addition to sending the form to
((}} a(a the addrea ) above, also submit one copy of this form within 30 days of
13b.Disi.Mdsa type:t- -f - Amour: Z✓Ft n completion of well construction to the county health department of the county
where constructed.
Form OW-1 Notts Carotins Department of Environmental Quality.Division of Waltz Rwowoes Ravirad 2-22-20 16