HomeMy WebLinkAboutWELL-09-2022-181299.TIF Catawba County Environmental Health
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SHERRILLS FORD, 28673
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Copyright 2023 Catawba County NC
03/23/2023
WELL CONSTRII ___-
GTIO ORD GW-1 For Internal — — _
1.Well Contractor Information; Use Only; •*n �...,,;
•
W CeTham 14?VYATER7ANFS
FROM To .'•..',.c:L::::r,s?,:ic: ieVi:of.',,14;;ii;`:.k. ',•-t•:ar.
NC Contractor Certification Number ���►'4CRq'fIQ4 -" s;
� ii_ -• !fs bl
( 45.`OUTER:CASING foi'in'
Comes N CC/ F1tU1f affi *ells OR'
Ilfjimilmin
1� To DIAMETER THICKNESS eQciible ;t- :a;::.;;;;-.:
2.Wei!Construction Permit lit vC_ 16 Dillnilla 5, 4 2 1
List all applicable well construction permitsLNG OR:TIIBiNG: `eutheiiifal el6ied:lo8; ' ^r?';t, .•••yt.,_, ,k,,,,
WC Colin,.State,Variance.elan FROFRO®� D/AM 7ER <:Y•,c....»r r.^�¢A
f e. ry, THICKNESS� auTeslal,MIIIIIIIII
3.Well Use(check well use):
Water Supply Well:
W Agricultural '17.SCRgEDT t ,:a�y _
�MUnici dl/Pu T..S To 1 VY.:';N'E;`.T.z; ,i7b!srr12:!i'?:i?s_•,.:1,W,: ... •4.,
�. .�, DIAMETER SLOT r.- atii;1. cii::S ,i:
111111.1
Geothermal(Heating/Cooling Supply) p P ble 0
R D®S— ram
II industrial/CommercialPP Y) ercestnential Water Supply(single)
10 1111111111
:I ,trio Residential Water Supply(shared) __
Non YI&GROI1Tr�.111,:�,?:itis{¢.>1r v..�•,:..:•c,
-Water Supply Well: FROM x; s:.t a�":`; ,: .
EMP v.''i:.,I•:?;'' A'G: :s +.iiiY,.',
Monitoring1+cEnmvrl►rerttoD B AM1f
Injection Well: Recovery J
oUN
IA Aquifer Recharge
}Groundwater Remediation i
Aquifer Storage and Recovery p—�
1111AquiferTest Salinity Barrier xvoN DI�VEGPA( C i:11111;1111113—;K; .;w
Mr
t.! Wit•:'; w±bea :i ifi::.��•, .s
IN StormxaterDrainage soo•�: ::
Experimental Technology ' 1 of>ctflop
IN Geothermal(Closed Loop) r3Subsidence Control 11111111111111111111111111111111111111
[Tracer
1 Geothermal(Heating/Cooling Return) =20.{DRII 1,pYG LOG attaeh"iiddlHo`o`id e
10ther f I.lain under#21 Remarks) ®� D hcac,r :;,• .' c?r'7';/ice xl;::
ESCRII`l1oN actor ha ,,_.
4. Wells)Completed: Z>y— r " 'L�
WelllD# �® • • t
4.Date Location:
Chia r .
FacilftY/OwaerName
Facility>D#(if applicable) _ ,
//' ` • CcPr Mill R.PhystcalAddress,City,and Zip zSP c 73 . IIIMIIIIIIMIIIIIimmu
County
-
,-du::Try $s1112. Ly ,:F.:Att:;:tw .7,.- ,t!. x;�. ./
.Parcel identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one let/long is sufficient)
0- ,
�'N e r r � 22.Certification: nviron 1: . -:- th
� !t
W
6.Is(are)the wefl(s) rrranent orTempora Si
ofC ed Weil Contractor /
7.Is this a repair to an existing well: Date
If this is a repair JFU out known well construction Yes or By signing this Jorm,I hereby certify that the wells)was(wen)constructed
with 1JAIVCRC 02C.0100 or vi NC4Cth Onu to Well Contraction Sr in accordance
repair under#21remarkssectionoronthebacko thisfarhm.on and explain the nature gMina ropyofthlrracotrl/uttbeen
provided to the well owner. Standards and that a
8.For Ccoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:
donstruction,only I GW-1 is needed Indicate TOTAL you may use the back ifs page to provide additional well site details or well
drilled- PLUMBER of wells construction details, You may,also attach additional pages if necessary.
9.TotaI well depth below land surface: S ITTAL INSTRU It)NS
For multiple wells list all depths rd$erent(example—o (It)
t�uv aiid7Ca)1op� 24a• t All ells: Submit this form within 30
10. •
Static level below top of casing: construction to the following of completion of well
Ifs atertavd water above carin&use top of
(ft.)
J Division of Water Resources, NC Processing Unit,
11. diameter: (j '' 1617 Mail Service Center,Raleigh,NC 27699-1617
12.BoreholeWell construction method: 24b. or Ia ectf a Wei: In addition to sending the form to the address in 24a
(ic.auger,rotary,cabin,direct push.a above,also submit one copy of this form within 30 days of completion of well
construction to the following: n►P
tc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELD ONLY:
13a.Yield(Rpm) // 1636 Mail Service Center,Raleigh,NC 276994636
Method of test: /, 't— 24c•
for Water Sunow * noon wells.
136.Duinfection type: z,�- _ the address e4 �addition to szndin 4, Amount: x also sobmit one copy of this form within g 30edays of
z completion of welt construction to the county
where constructed health department of the county
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22,2016