GW1--06288_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
.14 WATER<ZONES 1 : ..
NoFROM TO DESCRIPTION
Well Contactor Name ft. 1 I 60 ft.i 0,ype/
.i :t/li ENLAS1lvtiitor.main,cosedwellsjtiR°tiiNEHlif'appfrcable)`.'•..: . .
NC Well Contractor Certification Number z 1&CtO)6 Pet 1'42— tikt I i 411filir.(7 e FROM TO I DIAMETER TRICKNESS MATIIWL
..16:INNEIf,CASAti' OIt- (tikitherraBl:eloseda66p):_.
Company Name FROM TO DIAMETER THICKNESS MATERIAL
ft 2 3- 4' ft ft. in.
Z.Well Construction Permit#. 0
List all applicable well permits(Le.County,State,Variance,Injectio(,;etc.) ft. ft. m.
3.Well Use(checkwell use} Y7 SCREEN
.r t t FROM [TO r DIAMFTrR t MAT S17B 1 THICKNESS c MATFRIAi. i
Wuterr,aappiy'Welk I�: ft. , o,. t. iu...t t❑A cutturaf ❑Vunicipal/I'tibliC ' it. is i
•
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MAIL EMPLICiMENT METHOD&AMOUNT
❑Irrigation 6 ft. 1 G ft. b 4)fi°; rt tiAg V d
Non-Water Supply Well: ft. ft. Gd ar f r114,
•OMonitoring ❑Recovery
1 ft tr.
Injection Well: J •
t uagurrer Keenaroe t.Armunnwater Kemett;anon tt .. .OAtovrurctiv e.t✓r.Atfl U:afMiiaiiidi E ST, .HOD
_ _ 11 FROM .1 TO aaxx MATERIAL j
' •n •• ••• VJast111L s, 1iGi
ur,ai 11..+uw,uaawp++v,wwvwy. y ft:
❑Aquifer Test ❑StormwaterDrainage tt ft.
i
❑Experimental Technology OSubsidence Control •:Zp;;,pRR:LING Y:fGftittnchddd itio sheeisifntieasarl) .
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soWuroektype(UMW Au(ete l
❑Geothermal(Heatng/Cooling Return) DOther(explain under 421 Remarks) V
ft 0 ft (4 I
ft
ft•
4.Date Well(s)Completed:4,- ��g 'Well DM ft. ft. i v
` 1.
5ti Well Location: !` ft' i.
trial bok
Facility/OwnerNamc �i� Fact7ityiDti(if applicable) � f. L .`.%.,_...t. .,-, • t p ,.r.,i j
I ab 14•e" °�.r h ' Nu,51,11illcialfs, R. ft. •
Physical Address.City,and Zip `Y / .21,:RE1VfA tlfS • U 1 [U�1{
County Parcel Identification No.(PIN) [.'`6t'.c 'is
' Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees 22 Certificatluln:
IA wei5 i ein,aim 1at11w+t5aa aniticrentT If / _ r�{� Rn�
N W r„o: , _� 2. "�{—r1�{j' 15 s2 �1
Si Certified Well Contractor ' {�l J l Y Dot
6.Is(are)the well(s): llAermanent or OTemporary By signing this form.I hereby certi,,that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or t#1No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the Site diagram or additional well details:
repair underIt21 remarks section or on the back of this form.
__ , ,_a__i, ,_yaw, ___,_ _,,:,:_.._,_.7.+,zitz +..u-+- +( ++
IL Number of wells constructed: construction dehNits. You may also attach additional pages if neasanry.
For multiple injection or non-water supply welts ONLY with the same construction.you can SUBMITTAL INSTUCTIONS
submit one form. 1
9.Total well depth below land surface: 0 p (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 3200'and 2@100) construction to the following:
10.Static water level below top of casing: 1.0 (ft). Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+'� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: / y fin) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
2l above, also submit a copy of this form •.thin 30 days of comply ion of well
i.�J
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER slimy WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.}_
Lb°1t+/ 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection ty•pe: Amount2- well construction to the county health department of the county where
constructed.
Fueni(1W-i North Carolina Depia'inrent(A-Environment.awl'Natural Resources—Division of Water Resources Revised Aupust 2013