GW1--05898_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD (GW-I) For Interns Be n yt
1,Well Contractor Information; •
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Well Contreolo Neme ft, ft,
NC ell Contractor Certification Number tl .a b• " ;i>};!t�) �]TCf)"i� (Er1Y ftllFtt'lI[f1C�}tl�llalIl"s(try`i GLt'
FROM TO • ICKNE99 MATERIAL
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ft, ft, (' In. ) ;14
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Company Neale 9 • IOW li k S�)!AIsfrot 1iu 11?r`,lF}:ntali(Y't°)h°IYi.x?r VMS .. '•^ '`'
FROM 0 At u' IlltitlL•111 I•�
2,Well Construction well Permit#; ft, ft. r In,
Gist all applicable well construction permits(la.WC,County,Stale,Variance,ate) ft fL — In
3,Well Use(check well use); • t)6Xaa ft, rt, ;,►�'ii ?j I '..
Water Supply WelitAgric r;ou 0 D r e tTI7E1s]Iur�� ra
[ Muniolpal/Publlo «, NSECIAIIIMMIMINII
tL In,
Clooth Mural -- In, ��.
Goothotmel(Hoating/Cooling Supply) ERosidontlal Water Supply(single) tL tt,
Industrial/Commercial ( Rasldontiai Water Supply(shared) " ;iY(ct;�oT b" fl'> € iRl ' �'4§tli 3#
FROM TO rj1�,TE'IAL EMP CEMENT MET OD&AMOUNT
.I Irrigation ft, ft, '.)f' enl�2 .l ba•S / i
Non•Water Supply Well: ft, ft,
Monitoring QRaoovory —
Injection Weill R. ft.Aqul for Reoherge DaroundwaterRemedlattonO �t fgAI KhTv�;rQ�i i; t. f(i (1I lalfi MpLACEME T ETROD
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Aquifer Storage and Recovery'
ecovery ' Salinity Barrier t'Ou ft,
Aquifer Test [ Stormwater Drainage
\';. ft, ft.
Experimental Technology •,•,•• [ Subaidonoo Control ,...
t ' 'e 'It".rs Ti•�.' J'!"•fis.:,' '' ,.:,.
�tlTracer l�£f� s�l4LxQi?Xs�t11' �1, 41'I. n
Geothermal(Closed Loop) pRp TO Di$CRIPTION color hardnrsr rolVrock •r •rain raze tic,
Geothermal(Heating/Cooling Return) �"bOthar(explain under#21 Remarks) rt. ft, —
r, ft, tt.
4,Dale Well(s)Cortipleted; d��i-".2 Well IW# —
5a,Well Location; • ft. ft,
k t d'I)t_�r� Cif J a It. ft, —
/L anl� ft, ft, '
Faolllty/Owner Name Facility ION(If epplleable) _
ri / .1- / tt, ft,
Physics Addraee, ity,(end If triI§Cs:�� : ire ...y; ..• '°did
smentilli
County Parcel Identification No,(PIN),`.s
' —
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi•s 2Z,Certifications
Of well field,one latllong Is sufllolnnt) •
SlgristuroGerslffed WolitrFosor Pate
6,ls(are)the well(s) ":(Permanent �r Temporary •.
8y nagnrng this Arm,I hereby t rectoy that the milks)was(were)constructed In accordance
+ „owellsDYes or �No ' with/JR NCAC OW.0100 or 114 NCAC 02C.0200 Well Consfraction Standards and ilral a
7.Is this a repair to a^a=•-ti••. copy aphis record has been provided to the well owner,
Olds Is a report,Jill out known well bojrs!ruotlon l+t/brmatfat and explain the uan+re of the 23 Site diagram or additional well detailet
repair undo Nil rehrai kr eeti°n or on the book of this jots;.
You may use the book of this page to provide additional well site details or well
tho
cons�ruotlon,ronlyDPT or l OW-I is needed,oltidloatahTOTAL Wells
Tl(JMBBR of wells e
oonetrootlon details, You mayihi also attach add additional pages If Itnecessary,
r
9tttt ITTA1 lNSTR11 IIQ i$
drilled; �
9,Total well depth below land t+uufaces
U rj (fb) 24a, For All Weller Submit this form within 30 days of completion of well
For+nulrtph wolls list all depths(Pd(rerent(example.J(g200'and 2®100) construction to the following,
(ft.) Dlvlilon of Water Resources,Information Processing Unit,
1
if Static water level below top of casings 1617 Mali Service Center,Raleigh,NC 27699.1617
if water level is above easing,use"+'j
1p (in) 24b.For InteoNon Weller In addition to wl hl'nS30 days f othe adds ss eln 240
f wall
11,Borehole diameter; above,also submit one Dopy of this fo)Ytt
12,Well construction method;
}^6�ir`Y• oonettuotlon to the followings
(I,e,e,auger,ruler)'ry,,oecabble,direct push,oto.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mall Service Center,Raleigh,NC 21699.1636
FOR WATER SUPPLY WELLS ONLYI l
✓i Z4c,For Wa_____1eC tinDly $1-Intec---tt°n Wetlsp i addition tos form sendiwithng
n t30he for of
to
13a,Yield(gpm) Method of test; r the address(as) abovo, also submit ono copy
of� I I t G u S completion of well oonslruoUon to the county health department of the county
13b Disinfection types �111 Y t Amount ---�- whore constructed,
Revised 2.22.20I6
North Caroline Department of Environmental Quality•Division of Water Reeourcea
Form OWI