GW1-2022-09612_Well Construction - GW1_20221021

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ELL CONSTRUCTIOI�LRECORD(GW-11 For Internal Use Only:
1.Well Contractor Informaatti/on:
N rr I V`�[�'1 t --- ::•�'dr� ,i "r W i :;:�4%.•`K`0` =�_i_[„Yt:,c''�i.
FROM TO I DESCRIPTION
Well Contractor Name ft. ft. i
y596 A ft. '
NC Well Contractor Certification Number
C64k - ,A ��A Puyl 2 /r&s FROM TO DIAMETER THICKNESS MATERIAL
c IS �/' I/ [� ft. It, t. In.
Company '
P Y Nee 1_ ` �t,
��/ G 1 FROM tl TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc..)
3.Well Use(check well use): ft. tt. is
Water Supply Well: a
PPY FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural ©MunicipaYPublic HFROM
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt In,
IndustriaVCommercial Residential Water Supply(shared) , a Irrl 8ti0n TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ti{.i;� 1. 5Monitoring Recovery ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remedistion ., •b ,1 "EQ'bi r��? l ;u `a
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test 13Stormwater Drainage tt, ft.
Experimental Technology .N; C)Subsidence Control ft. tt.
.` ;�x. 't3D G''li .l,..afi,!:«..a.� ,, '68fbi ferle�'• `„ :�4:=y"s,:;��s'@&^'�`<r?ic<�<��'��:^'_
Geothermal(Closed Loop) Tracer
FROM TO DESCRIPTION color,hardneu sollfrock rain size,etc.
Geothermal satin Coolin Return) ;Other(explain under#21 Remarks) FROM
ft. C�nIG ft.
4.Date Well(s)Completed: 0A17122 Well ID# Lie ti' 3(iv ff Yot,11.t1 e,
�- °
5a.Well Location:
ft. ft. ; �°'�'
�►-�L�--(�Gwe.l I G���
Facility/Owner Name ` _ Facility ID##(if applicable) ft' ft' OCT 1 202
6YTAnt1 V 1,Ls�tIV 4CJC''t2 & • rl -L1(f' ft. ft. iiFSof7ti " r ,
Physical Address,City,and Zip -
:Zti�:' $-s - _.L4` .3..a;� � �. pia,+,i:^�..)f`F�S•E',.;-� ��. 3 , r -. .�1
AGPa>,�•��I
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(ifwell field,one let/long is sufficient) 22.Certification:
35r567q� N 81.8956 ( w z
6.Is(are)the well(s)SPermanent or 13Temporary
Signature of Certified Well Contractor Date
By signing this fornr,I hereby cerllfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well; DYes or .JNo iv!!h ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Cowipuction Standards and that a
{fills is a repair,flll out known ivell construction hitbrmation 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 ojthis form. 23.Site diagram or additional well details:-
8.For Geoprobe/DPT or Closed-L Geothermal Walla having the same You may use the back of this page to provide additional well site details or well
oop
construction details. You may also attach additional pages if necessary.
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(derent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:, d (ft.) Division of Water Resources,Information Processing Unit,
ff water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.) 24b.For Infection Wells: In addition to sending the form to the address in 248
y�
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A c +G t. ✓ 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: AA 1636 Mall Service Center,Raleigh,NC 276994636
13s.Yield(gpm) C Method of test: f+i r 24c.For Water SunDly&Infection Wells: In addition to sending the form to
�r •the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C h�d r 1 Y1 4. Amount: S completion of well construction Ito the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016