GW1-2023-02463_Well Construction - GW1_20230404

Print Form
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1ZeH C otractor I o matiop -
((!lffi�• d `r"Y- - 1'4,'VCAT R.ZONES
PROM TO DESCRIPTION
Well Contractor Name ft. ft.
t=)6 yj, , ft. f
NC Well Contractor Certification Number /��7 15, TJ R.Ck .G'.farm ~Cased wells OSPA V
PMR.Sffa' cable MATERIAL
/'Ct l�I S WPil' 6t✓�d l U FROM TO D TER
/lam fr. fr. I ln.
Company Arne 16.' ':CASING Q G 'edtfiarm'eUV FROM TOBS MATERIAL
2.Well Construction Permit#: / V rt. fb to
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft, ft. hL
3.Well Use(check well use):
Water Supply Well: FROM To DIAMETER SLOTS IZE THICIOVFSS
10.
. MATERIAL
Agricultural E)MunicipaMblic ft. ft.
Geothermal(HeatinglCooling Supply) aR@sidential Water Supply(single) fr, ft. fn
Industrianommercial oResldcndal Water Supply(shared) 1s..
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ILi! alien
Non-Water Supply Well: Q it. 02o it. +'
•Monitoring DRecovery ft, ft.
Infectn Well: ft. ft.
Aquifioer Recharge Groundwater Remedietlon 19,SANII/GRAVEL FA. IE rt a ll a le
Aquifer Storage and Recovery , Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�.;. ft. ft
Aquifer Test ;;��; �StormwaterDrainage
Experimental Technology Subsidence Control tt, fL
Geothermal(Closed Loop) OTracer 20.V LINGLOG. ttsEh' ii IHDn :sheet:ifaeeessa
FROM TO DESCRIPTION color herdaess soulrock alze etc
Geothermal(HeatinglCooling Return) Other(explain under#21 Remarks O 110 fr, C A
4.Date Well(s)Completed:A, 47-3 Well W#^ _ ft- 5 VL4
rt. rt.
Sa.Well Location: - - - 7.
f . il� r:j
C h e �m 4S� ire e W a`O Yu� a v.'
Facility applicable) ft.
Facility/Owner Name ry IDN(if PP ) l a L L
M ft.
Physical Address,C ,and Zip IL
ZI.REMARKS
CI S�I'l
County Parcel Idontificatioa No.(PIN)
5b.Latitude and longitude In degrees/minutes/secon4s or decimal degrees:' '
(if well Gold,one Iailloag is sufficient) 22.Certification:
3S,59g35 N -81 ,,213 77C w
Si hue ofCertitled'WellContractor Date
6.Is(are)the weil(s)*Permanent` �or.[3Temporary.
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: ®Yes or Nlo with ISA NCAC OTC.0100 or 15A NCAC 01C.0100 Well Construction Srandardr and that a
if this is a repair,Jill out known well construction triformatlon and explain the nature ofthe copy of this record has been provided to the well owner,
•rdpair under#21 remarb section or on the back of this form. 23.Site diagram or additional well detalls:
8.For Geoprobe/DPT or Closed-Loojl;Geoth'crmal Wells having the same You may use the back of this page to provide additional well site dotaiis or well
'
construction details. You may also attach additional pages if necessary,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: _ _ S BABITAl.'i1VSTRUCTIONS
9.Total well depth below land surface: J , •5 t (ft-) 249: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(/)erent(ezagrple-3@200"and 2QI00� construction to the following:
10.Static water level below top of c8311194, 60 VQ Division of Water Resources,Information Processing Unit,
If water level Is above castng use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.) 24b.For Infection Weill: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A e)&A- construction to the following:
(1.e,sugar,rotary,cablo,direct push,etc.) (f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
•5 Method of test: �t r 24c,For Water Supply Bt:Infection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type uJ i n e Amount: 2 C U -s completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Re our cea
Revised
Form OW-1 2.22-2016