GW1--06184_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
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1.Well Contractor Informatlont R s
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Well Contractor N e tt, f6
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NCWollContraotorCenlllostionNunrber a °1L�'1(;`''�°��}DQ �` `Ljjiul ltll�rii:TL•l;!�I''•Ili
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Company Name 1-1
) L' ri/) fJ.i�,►r.I�sU 151��1rz1CL2IV!IU3r'I?�I41.(f•l:itir t)N•li�021-ix 5`1! rJ►74 Yee/`— �t0u �i�'�L�uLh :�_ ,—__,tlT]� u2,Well Construction Permit Ntrt,• ri' �—
Glsr allapphcablrwillcaraoaarlonpena,UIC.Couuty,Slat..Varlanee,.e%) rt. rt, ��
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3.Well Use(check well use); 31/1111l;�_} y (a�MEMIl,,s't( ��,r i YvY '►'b:K ').1 '1 f' � lM
Wetersu I Wells ►;."t�r"�u ,`I �
IIEMIIIII
Agricultural 13Munlolpal/Publlo ft, ft, I ' In, MN
• gili aeothorinel(Heating/Cooling Supply)
Residential Water Supply(single) ft, ft, i. , In, ' M�
Xi1lndustrleUCommoralal RealdOntlaI Water Supply(shared) nam;tole' om 'is'fx 4�raymommo
�T a'• ` • T�' °p&AMOUNT
Non•Water Supply We11t tt, n•
*'Monitorin: )Rcoovory
IIIIIIIIIIUIIIIIIIIIIIIIIIMII
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;1 AqulferRoohargo , •, aroundwaterRemedlatlon WOOD
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EINEMEM
le Aquifer Storage and Rsoov®ry �Saiinity Battler •:o u
' 3Iormwater Drainage n. re.
181 Aquifer Test :;;t . • g,. U.
I
111 Bxperlmental Technology `';,�5,?b` ' EiSubaldenoo Control -
Rl '1ll'r>?J a'iJi�ii)',t,,: ..;.:.,...
(h`fiaie1IEEJ?39Eff C�1 fiN111 r- rL f-91A11i(t, •:.- .i
,1Nil�aeothermal(ClosedLoop)`� �Traoer �olil• �, DPaCRP ION 000rherdna ,o�raek ,, •rolndze',Ie.
*Geothermal(Hooting/Cooling Return) Other(explain under N21 Remarks) a tt, i 0 Cl. 1 — 5 /'t-.• G. G
d,Date Wells)Codt�letedt, i)"d J1' Well IDO 6 f6 51.55rt'1 4 y"jQtt• ' -- Y
tt, ft,I U.'t;�.4�A,•a.
Sa,W l Location' }— ft. ft,;
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Feolllty 1D#(Ifeppileablo)
FsollhylOwnerName ! ` ft, rR ".., i.
L— r e.'I , Zip 1 ft, ft, L.•vi,,,..i�3
Phyalos(ll ddrom,Ci y,and Zip Fatly;•� t���i•�,d,+ b'Ibif 32 l Aid . '1.;,;' ,.•. .,.
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County farce!ldontlflcatlonNo,(PIN):',a
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees(•% 22,CerdtloaHont I •
Orwell field,one let/long Is sufficient)
1 (/y
8lgdatureof� tied Well Cont r
Dale
6.Is(are)tbe•weU(s) Permanent �r 'Temporary $y signing this from,I hereby oer!(!y!hal the we (s)was(were)contracted(a accordance
WA IJA HNC 010,0100 a'IJA NCAC 01C,0100 Well Construction Standards and that a
cf Isi is a a repair to0u anIf existing well;. QYea or �No f copy gltlds record has been provided to the well owner.
Uthlsrsarepair,Jilloutknorn►wallconslraorfonhtforma►larandexph;radreabnrrc:o sire-; 23,Sitediagramoradditionalwell&taller
repair under N I rrhrarkt.!fprlon or on the back oflidsJbrwr, • '
e to
rovide
ional
e
the
construction,onlyOW-1 lePT or lnaod dpo •
l!tdloa ohermal TOTAL Wells having
of wells e
coo Dirac I use the on details, You may alsopag attach additional pages if well sit necessary,
or well
drllledt
9,Total well depth below land siii facet O (ft') 24a, For A11 Wel1ar Submit We tbrm within 30 days or completion of we
l
permulttplewellsIlsealldepthsIfd(Qir.++l(example.'®200'and7®00') 'constructiontothefolioivingi
„ go (tt,) Division of Water Resources,Information Processing Unlq
• 10, er le water level belowg top of caeingt 1617 Mall Service Center,Raleigh,NC 27699.1617
11,Btinter level k above•oash+g,use + addition to
e address-In 241
s 1 (in.) aboFor In submit one copy
of this form within 30 daysf completion the lbrm to h of wel
Bordhole'dlamotertabove,also submit onaI copy
•`/`ethod; 6 I L- lJ gonetruotfon to the following;
12,Well aoastrou blo,dlroot push,oto,�T
(i.e.auger,rotory, Division of Water Resources,Underground Injection Control Program,
• 1636114 I 1 Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY; ► _„ .-_- .enty.8a Inleation We11et in addition to sending the form t
i 2Ao, of this form within 30 days o
13a,Yield(gpm) - Method of teen the addresa(cs) above; also aubmit ono copy
t Gam. S completion of well construction to the county health department of the count
Amounts where oonatruoted,
13b,Disinfection types Revised 2-22.20I
North Carolina Department of Environmental Quailty•Division of Water'Rosauroes
pormOW•l