GW1--06276_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor fngf�yolrm 1 �Ywd �y�•�+ � yyl� pro? m1 y4
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Well Contractor Name t� = FROM TO DESCRIPTION
ft. ft. f '
its 5,4 ft. ft. I i
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• NC Well Contractor Certification Number •
'11$ R + i((0ttii01 ?;yrjj` callj)l:R3I, *`Ott hall i�us�-'�``)A'z::`.'i
P 62, , 1nG' FROM TO DIAMTER THICKNESS MAT�E/RIAL
Ca wide lrt�el r�{�l,�J -C I. ft. ft• i in. sD 02..E V •Co -
mpanyNa e It ss ;�.� .x
1144?1�NNRik�i � �lYpttkeGtlfd'..11i�1diitlndi�iu'�.;��':��.;:i;Ei�»,:a3::i<<:..
8y(,j,14 ( , FROM TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit#: ft. in.List all applicable well construction permits(Le.WC,County,State,Variance,etc.) ft..
3.Well Use(check well use); • ft. ft. in.
j41r7SSfiltA( �'. ••Sid ei p1 }u.•=t`�s raW.` i5" 'With s s w.',q•.,•..%i)'.'i}''j:&;.
Water Supply Well: FROM `TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
Agricultural I MuniolpaVPublio ft. ft. f M.
Geothermal(Heating/Cooling Supply) ggResidential Water Supply(single) ft. ft, ' 1 in,
• Industrial/Commercial • 0Residential Water Supply(shared) bloom t,y.mwed: ., r; tb,gm.;. ;s%,;I a0t;m zt;;, l fw^a;9n' .
Irrigation FROM TO L RIMATERIAL EMPLACEMENT METHOD&AMO
Non-Water Supply Well: 0 .to• ,1_D ft' U e_ e n l�e /'4 bt-s tat Arad
Monitoring DRecovery ft. ft.
Injection Well: •
ft. ft,
Aquifer Recharge DGroundwater Remediation ;toµ:,,; .,: „ ;�;
619'S'AN /bA' igll t(tf�#11PUCIl 1014; ''f�r`04 . :i,r.�.i :_�k;•�<it'Li it�ii:,.�...MA
Aquifer Storage and Recovery ` DSalinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test - t� 1 • DStormwater Drainage • ft. ft. .
Experimental Technology • Subsidence Control . ft.
P '�•.'. 0 ft I
Geothermal(Closed Loop) k DTraeer 7 010 ttF 104iQGkt(altab}ilti'd'dliib5fblab'etii�'+'Ctkecerflni)'1 ''':8}:si`:=:c(;l lihiii:-'
FROM TO DESCRIPTION(color,herdeeu,solUrach type,groin elze,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) U rt.
It ft, 7/f' y'-i 7/ 5 )/ G/ct-y 7
4.Date Well(s)Completed: ei-0/ Well ID# A1 3--ft. l05ft. . la rho f'L
5a.Well Location: ft. ft. r--� w ., rr'•�,,
`/ we- ft. ft. p
Facility/Of�wne/r ame �• Facciiliittyy MN(if applicable) SEE v 2023
r • %0+`^ Cis�Q f-V U� • / I / ft. ft.
Physical
/Address,
�/City,and Zip CI1 t°
/ ft. ft. inform r^. Sa`�
Y '?ing UFn?
(may i."/,ij?i�yM legfAi:. ar=i4•. ,:cifg.ii:i. it.�v:ke.;4�.i.
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County Parcel Identification No.(PIN) - . •
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:; • '
(if well fiield,one la/Nionng"is sufficient) 22.Certification:
.. 4,4„./.41.- ,11.4W74--- I-X-7-;21
6.Is(are)the wells)f§Permanent Or.... Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert{jy that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
UYhis is a repair.fill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
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repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop get thermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 o..6-- (ft•) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multlple.weils list all depths((Afferent(example-3 c@200'and 2®100) construction to the following: I,
10.Static water level below top of casing:: IOU (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: 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:IO t 4-' construction to the following:
(i.e.auger,rotary,cable,direct pushy eto.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) •f Method of test: A J Y' 24c.For Water Supply&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 types 1 -///e3 Y/�')e, Amount: ,r� completion of well construction to the county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Reso Ices Revised 2-22-2016