GW1-2022-09596_Well Construction - GW1_20221021

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' 1 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information: d� p , I
!M r y C� N a�—1�I{—
61.y,.' r='air;3 Ens'$::; iY'SSa" >"`:.�+2>i•47� >Y% crs:::�i^?`f. .i`fi3 :1[,fc z..
W FROM TO DESCRIPTION
Well Contractor Noma
ft. ft.
�.� 5—A ft. • ft.
:,.;
NC Well Connector Certification Number ;vl E =gJ s{ "' to e (. 1!T t+s I ii h .
n ',,A n r pp p /► Tn�i. FROM TO DIAMETER THICKNESS MATERIAL
( Q iJ S Ci'I / �mN . {� f tt. g ft.
Company Name
'> :CA s' •� �. i k tie .. � -�
2.Well Construction Permit#: )� /I Z- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC.County,Slate,Variance,etc.) n• ft. In.
3.Well Use(check well use): n• tt. is
Water Supply Well: JY!/ ..
PPY FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunIclpal/Public ft. I ft. in.
Geothermal(Heating/Cooling Supply) Q esidential Water Supply(single) ft. ft. In,
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. it. p✓fir `� S
Monitoring 13Recovery tt. n.
Injection Well: ft. ft.
Aquifer Recharge 00roundwater Remediation •-",".k. z;<}
rll t ; .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �. 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) DTraccr ISOi�11 ti+ i c `tl b `? 'se [onTt' $`. .�•. k? .�
Geothermal (Heating/Cooling Return ;Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardoeu iolUrock enip,grain sim etc.
4.Date Well(s)Completed: L)-;VW ll ID# ft. �t b ft' f XYl I e,
So.Well Location:
Facility//OOwnerName Facility ID#(ifapplicable) ft. ft.
71 / G t't i(1 A 1+e sb x_ d ft. n.
Physical Address City,and Zip r A
' 77077
Po I �a`;'�si,.ar,3N; w%:�'�,:xi a i' r:.a' �J> :t•.ia3 ''1=r.
County Parcel Identification No.(PM)
Sb,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/)ong is sufficient) 22.Certification:
3Sa3aZgI N —9,2-D13l24 w ��� � AD J- zo
6.Is(are)the weti(s)fl�Permanent or OTemporary Signature of Certified Well Contractor 0 Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an.existing well: [3ws or JffNo with ISA NCAC 02C,0100 or 1JA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,JNl out krrown well construction/q/ormratlon and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the-back ofthisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �_� (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f d(oerent`(example-3@200'and 20100) construction to the following:,
10.Static water level below top of casing: to (ft.) Division of Water Resources,Information Processing Unit,
tf water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �O (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
I O�G�Y y above,also submit one copy,of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Gil r 24c.For Water Sungly&Inlection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: *)- G completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016