GW1--06341_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Info ation:
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r¢y� f4'�KA 1 ER ZONg3... !' I
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FROM' TO DESCRIPTION
Well Contractor Name
�C I Ac• p f4 - .. i'.F7A�� O ELR'�TE£'�:(ifa " btu') `:
•
15�8);1TP3:C1t�IIlmiy dfa7 inubi saxes!r;;:lisl g p��.Ci
)��ti'cll COd.i ttYi C.�„t1fi�Goe umber
4i canna i a•n 1 nvouvr O 1 •rrarr trarcc 1 srA�r�.-nrAL
4 - Oft 40ft1 ( / , in. 1 *)' Igat tltte?
�� Coe, �� ` A�: AEG;DILV RING(gintherniirlitiriAtiaop);;
Company Name j FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit*: Cast)
3 q 5 1$41 ft.., -ft.i An.
List all applicable well permits(i.e.Counry, te,Variance,Infection;etc) { "m
3.Well Use(check well use): MATERIAL
FROM 1 TO 1 DIAMETER 1 SLOT SIZE 1 THICKNESS J
Water Supply Well: � s µ,:t• r' ;I tt
lDAgicultilral CI I)'unicipal/Public l .[ ,�
• I 1
Ueminnettnui kneaungti.uututg auppiy) tcesttiottuai water ouppty tsuigtc) 1
°Residential Water Supply iB-GRQ)UT
°IndustriaUComrttercial � ly(shared) •FROM To MATERIAL EnPI.ACEniEv'c METHOD eaMotlNT
°Irrigation 0ft. 2,0 ft. ,14,,I..6v,. ortravii.7
Non Water Supply Well: ', ft.- ; ft.•., r���'yt,�J�
L7N[onitoring DRecovery ft.- ft. nn "
Injection Well: t
°Aquifer Recharge OGroundwater Remediation 19i SARA/G11A:VELPACK"C a0L )
MOM f Tr) l M%TFlttAL ! EMPLAC1:AC"[Tt MIIOD
uwqutierstorage ana Kecovety usaimity rsarrier 11 it 1 I
-
M
°Experimental Technology ❑Subsidence Control 10,DG (, ,aoniilsLeetr;3fneeessuY)'
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTI N(calor,hardness,sa-IitocktMe,Main aiu,etc.)
°Geothermal(Heating/Cooling ) °Other(explain under#21 Remarks)1 1 0.ft 0 -ft' �-./1","l '
'SO . . 00 j r hvt-f...., r6 bk-
4.Date Well(s)Comppleted:4 (q 2 q Well Iif# fL
Sa Well Location: - • I -ft 1
�� 1
Facility rams Facility ID#(ifapplicable) ft. ft. .:� • "�•� ,,,,,��
Tel P.,,e. RE)3t. sit Le•l�.taY ft. aF► (014'PhysicalAddtdreee�ss,City.andZip 0 r:218EliiiiRICfi. . ... If
tl (�h141 4i 'tr-- rdmro 1r_�
4.4 r-i :...e r,v I,co,
Can, Parcel Identification No.(PIN)
51):Latitude And Longitude in degrees/minutcshteco:tds.or decimal degrees: tz f p,ht;rAtinn; , �j
tit welt weld„one latnorlq Is snf'ficient) 2 {rp
N W �Tp
Signa fCertific Well ntractoc Dat
6.Is(are)the well(s): lPermanent or °Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or liNo copy of this record has been provided to'the welt linnet:
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well detti►
repair under a21 remarks section or on the back of thisforru You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: •1 construction details. You may also attach additional pages if necessary.
FORmullIple infection or non-wokr suppli1relll ONLY with the sturte construction,you can 12141EMtTTA) I1.61CTl7l'r't[ANC
9.Total well depth below land surface: 40 0 (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 00'and 2@100) construction to the following:
If
Static water level below top of casing; (ft:)
Divisiois of Water Resources,Information Processing Unit,
If:racer level is above casing.,trse"{'' 1,b�?flail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. `/LI (in.) f. 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
'24a above,alstr submit a copy of this form within 30 days of completion of well
12-vdell euusiruciiuu nieiuud:, " 4 Orf reiritoki construction to the fouiowiit
(i.e.auger.rotary cable direct pus .'eie) ." •
a,tewtuu ua VI aada trcauuai.ca,uuuctgsuuau istje:uuu a.uuuvaitugautil,
FOR'IOA.7iVATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
10)()° 24c.For Water Supply&Infection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30'days of completion.of •
_ 1 S_ Amount, 2. NA '' well construction to}the county health department Of'the colmljrWhere
13b.Disinfection type: '4'V11/ constructed.
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North Carolina Department of Environment nod Natural Resources—Division of Water Resources Revised August 2013