GW1--06301_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor NCI
:,T4 VAIEREONEg 1..•+ . .. • • .. . .
w�
' 1 pa 1 C I Is. FROM Tft. IO DESCRIPTION 4y
Well Contracted-Name . ll.`. i l UI 0+
a i x 15.U 1`►P7F[AD11Yl�(for-rimulri case+k:cbetisTt]1t LttrtFR(W nP R'M I M.
NC Well Contractor 'fication Number FROM TO DIAM)TEtt THICKNESS MA
r.) a m I �S ft. ` 1/4'° 1 a I S S :.. 64 Vs.il roe
G@ 4 11 o �' tAi 6{ �4�P (J), 1. . 1rrAsll�rc;ox=�rlls> a-( iher»�,��ed4iimi �. -:.
Company Name FROM TO DIAMETER THICKNESS MATERIAL
' ®0 01 1, ft ft. in.
2.Well Construction Permit#: 613 ecdon,.era �
List all applicable well permits(i.e.Cotmty,State,Variance,Irj ft ft
3.Well Use(check well use):
-t'.FROM PTO ( DIAMETER 1 i SLOT F.. .. 1 THICKNESS MATERIAL
.<. ft t { I 1 l
_ Water Supply Well: t, Et.
El igricutturat Cl unicipal/Pubfic it ft J in.11
©Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 1.
1 . .:.
❑Industrial/Commercial °Residential Water Supply(shared) FROM To MA EMPI.AM• +ry,r METHOD et AMOUNT
❑Irrigation ft. 1..0 ft. kilt&ift
.c.Intym __0
Non-Water Supply Well: ft. ft. (i[
❑Monitoring °Recovery ft. ft. I
feA
Injection Well:
t.it,mlindwater Kemeatatunn I r1.,ia3VUtbrtPi.Y'1'.b raga ULai:unmanre3+ •: - 'r AICft30D
t l.lAgtllter KerfiarQe 1 FROM 1 TO 1 MATERIAL I
1 B MPMCEME
• u.�a:n..i ira.ri05 f. ft.1
urryu.u.,MS.able Mill..wvv..,y 7 I
°Aquifer Test ❑Stormwater Drainage ft f.
°Experimental Technology OSubsidence Control rDLO,Lsddda;tiaawtsheeieifaeasuxyl
❑Geothermal(Closed Loo wr
°Tracer FROM TO DESCRIPTION(color,bdiless,soil/rack Eine.t�ems. 1 ..
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft• 3 0 ft c'i 1't/
a an 4.Date W ells)Completed: Y 1 V`r�'Well 1D# ft. `^ft• -I. '
38.Yf eiiLo iron: ft. 1 ft. Fl) ...,—, ' - __, j•.
ft.
Facility/Owner Name . P a
Facili JD11(if applicable)
ft. ft. u�,,T 2 G 2024
}
Physiica�jbaAddrest City,and Zip B .2I:.RREI(IARKS` .: .-.1,,:,,'....:
.__ .
County w V U S q�///�/�p�ya�/Paarcel.IdentificationNo.(PIN) I ,
- Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
to well Slcdi.vno neural;utiuSSn:iEn{1 ! I1 -'L 9
/\
_2ALi
N w `���"" Date
S• e of Certifte ell Contractor •
6.Is(are)the well(s):'Permanent or ❑Temporary By signing this form,I hereby cert(fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or 14o 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 or additionaljwell details:
repair under 1121 remarks section or on the back of this form. 223. __diagram,__,_ M o:- •- __:,- -,,:•:-__+---++ ' -='- ;;"
ukt-114y Miz'uA.Vuvt v.u0J�Y ,w N....+u..wuw,wuw n14a. u..•LLuo 11
&Number of wells constructed: construction details. You may ti}sv attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.yvn con
submit one form. t / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 - b (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@200'and 2@.100) construction to the following:
10.Static water level below top of casing: 20 (ft)- Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter: �4 p(in-) , 24b.For Infection Wells ONLY: In addition to sending the form to the address in
or 2'ia above. also submit a c p, of this form within 30.days of comp ctiun of well
• _ _ q�-r (' ■ 4M.M:_.-.�:1�cur:-H.a:I v �.
(i.e.anger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1.5 Method of test 1VAI24c.For Water Supply&Injection Wells:
th Also submit one copy of s form within 30 days of completion of
't ,j, well construction to the county health department of the county where
13b.Disinfection type: 'A Amount: - constructed.
Feria GW-I
North Carolina Department of Environment sod Namur Resuurues-Division of Water Resources Revised August 2013