GW1--06276_Well Construction - GW1_20241022

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.,'-s• For Internet Use Only:
WELL CONSTRUCTION RECORD(GhV-1)
1,Well "tractor Informatlont n
' a-r e itJltl'PROMf�!��`'�T°o�.,"ice, ,,. . �,A►a3�r's�,r`�;,ax.. .r. ,
l^ ci6 e DR@CPTri�_
WaIlConhra/otor✓Nemo-[ S' ft, ft' I
4f 6 2 .a—A ft, ft. I '
NC 11ConnaolorCettltloetlonNumber .�l- P�J1 S�f�lni stilt' 91)Ab1Y(! °`' " ':! 'd Ri 4]I l�l:pi13(tj dull dlbf%:
,/ L�/ I I Y I LQ ��. ..,....: ... .,
FROM TO D AM>rTeR 'W1CKNesg MATERIAL
�YC� l yiC,•
• ft, ft, ',, g ' 01 et j P
Company Nam • / r tiT6 ll!INo11? 'A'�' , r I: '` '•'t51Yi:•Pfpl�4 ,:.,I,:::1.
P Y W v�4/ 2 7 m /y �t ri Q PROM TO DOMETP& Td1 EBB MATERIAL
2.Well Construction Permit lit �(`T QL /J CJ at R, rt.
Gist all applicable will consnactionp&rmits(iv,UiC, unty,Slate,Variance,etc) rt. In,
3,Well Use(cheek well uee)i ,. 1 ;sJ,p,�f j „;.:•},,,:
Water Supply Well: FROM TO DIA1,•
m a1,01MEE monism MATERIAL
1111 Agricultural DMunloipaiPubllo ft, - ft.
• MI Geothermal(Hording/Cooling Supply) BRosidontial Water Supply(single) ft, ft, •;. In, '
[ Rosldentlal Water Supply(shared) '.), 11`, (Y r '(i( RA co,.ye..,•',;:vir,'f�N"�.{'Ow`i4�":•:::....r
.,•,Ir Irrigation
pP y , Ego �'e TO r {1�ATER AL r EMPkACEMENTMETHOD&AMOUNT
•
LslWate fG tee e e_tu ., I-a a-re_J- iz- .[)�G 6
Non•Water Supply Well: © .., �d .
"Monitoring
r3R000vory ft' ft'
Injection Went fh It.
Si Aquifer Pecharge �CtroundwaterRemediation r411; Nit/d. .N�;, -i'i,(c• g,l•-!V .)::q�:1. 1) :�,:•r..;•:-a'jr>.;:
•
'Sannity Bonier gROM TO M ERIAL EMPLACEMENT METHOD
1M Aquifer Storage and R000vdry� ' -
d•..,.�I Stormwator Drainage
JihAqulfbrTast � - ,
,'�� ' gubsldenoe Control ft, ft.lit Experimental Technology .;,, ., , r
Si Geothermal(Cloned Loop) DTraoer PRO TO DEBCRiPTi N Woo hardnuu us) rock rldn vain deer'r1cJ
Geothermal(Heating/Cooling Return) 1t-Other(explain under ti21 Remarks) 0 ft, y ft. , _yp / 5' .
4.Date Well(s)Coih�lletedr `/D'`'1 074- Well IDH . , 7I ti' a4c a' ri t-a
rt. ft. •
Sa,Well Location; �' . tL ft. G ,. : .__.•; Tr' '
•
b � �L�Y :.l 1y -s• h :•
Facility IDB(If applicable) ft, ft.
Paolllty/OwnerNeme 81
13 y ft, !t, (Jl,, � J Z 2024
Physical Ad rerr,Clly end Zip / 4 �,s�••i. ,? s v
g still + ;, e4�'sl107i6s ��l .::,.:., ,•
County Parcel idenllfiaiionNd.(PIN)_•s
D.Latitude and longitude In degrees/minutes/seconds or decimal degreeni'I • ZZ,CortifloaHont
•
(If well geld,one IaVlong Is sufgolont) `
9 a-�i44,e. N ''l, qa4 ' w fj / — -
/ .M s is _9lgnaturoof�erllped yell Contractor • Dale
6,Is(are)the wen(s)�Permaneot -Or.�`j'emporary` By sliming this Jbra m 1 hereby me That the well(s)was(were)constructed(n accordance
�•�st with 1SANCAC 01C.0100 or ISA NCAC 020,0100 Well Construction Standards and that a
T,Is thee a repair to-an existing weUr Yee or �,o � copy q/'llds has provided to the will owner,
(f this is a repair, 111 out known well bortslreotlon l,l/brmallott andte explain the nature Oho copy
isdiagramrecord orn been additional well e l o t
repair under NI rehmt#411 l►on or on the back oflltls firm,
You may use the book of this page to provide additional well alto details or well
8,For Geopronly I O or Is n ed� po 'Gltigthermai Wells having the same construction details. You may also attaoh additional pages If neoossary.
of wells ,
dolled: tlon,only I OW-1 Is needed. Uidtoafe TOTALNUMBER8U flMITTAL IN8TRU 1 IONB
drilled; •
9.Total well depth below land tit:facet " /',.3011.4 24a. Far Ail Wetfet Submit this form within 30 days of completion of well
For multiple will:pi all depths(fd(brnN(!xample• 1 and 161 00') construction to the followings
Q • (ft.) Division of Water Resources,Information Processing Unit,
((1 erle water level below top of casings 1617 Mall Service Center,Raleigh,NC 2769.9.1617
(f wafter level is above oiling,use"+"
11,Borehole diameter' f 4 (in,) 24b.For Inleet1on Weliatpin fopaddition to a hiing th days t oche address-In
des of well
above,also submit one copy of this fo
etion
iz,Well construction methods
.ID CA-- construction to the following:
(I.e,auger,rotsry,cable,direct push,etc.) Division of Water Resources,Underground itaeatlon Control Program,
1636 Mall j9e'rvlce Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY: „nDfv t&rirfeatlon Wejlgt in addition to scolding the form to
,r / r 24o.` of this form within 30 days of
13a.Yield(gpm) 17 Method of tests the address(es) above, also submit ono copy
' CL. 5 completion of wolf oonstruotion to the county health department of the county
13b.Disinfection typo;��Amount' where oonelruoted. Revised 2.22.2016
.,_-a.n-...Ilim neoettmertt of Environmental Quality•Division of Watef Resources w A