GW1--06624_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD Por internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Inforna.tiou:
.. IttL, Dki4 l I'S . . .
tl t.Wi1TLtR>ZUNES r.::...,: t ...,.,.._..
PROM TO DESCRIPTION•
Well Contractor Name ® ft. ft.
a 038 - � moo �• 99,���.
�DDft. (�O®ft. L Il�t+
NC Well Contractor iticatiorNu;pber ,15:`:OUTER:CASING'(fnrtnulK•eased'ivcUs)OR7;1NI R'(if uii"IIuiblc)":?''":'t'•;•C" .
f _��� ,1[r)�(� � ' l��� ��i�� '� FROM. TgO Q DIAMETER. THICKNESS MATERIALy't
i�/J .Its W I rt. /( G 't la°!'7 �n ✓dIIC Z. ! lr
Company Name t.16::INNLIt•CASING.OR:TUBING:(gaotliefniahclosed-loop)', '.:.--`.' :: ...., _
�0 /_ FROM TO DIAMETE THICKNESS MATERIAL
2.Well Construction Permit it: l7 ft. ft. in.
List all applicable well construction permits(Le.Comnry,Stale,Variance,etc)
ft. ft. i hi.
3.Well Use(check well use): ' •
'17:SCREENII .,..::'•.':. 1:a y, ..
PROM TO DIAMET .SLOT THICKNESS MATERI
AL SupplyWell:
❑Agricultural ❑Municipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fr. fL in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM • TO MATER L CEMENT METHOD&AMOUNT,
0lrrigali0n fr* aS rr. ' '/
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Non-Water Supply Well: ��� ir�
❑Monitoring ❑Recove ft, ft. S'.it3 a
LvV7 ry 7 �
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .197SAND/GRAVEL'PACKiif linlirnble};;•:'.:=;,'•...;.:y::.'.1...:',"-.1..:'•>:::•'..1,‘•1•:
❑Aquifer Storage and Recovery ❑Salina)'Barrier PROM TO MATERIAL EMPLACEMENTM1IETIIOU
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Gcothennal(Closed Loop) OTracer '•20.`DRILLING.•LOG(nttoch additiorial'sheets ifacealsnry)' ::,•:!::'.':;.,,.;!1•:y
FROM TO DESCRIPTION(color.hardness,sell/mak type,groin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft. t D ft' �D L .
4.Date Well(s) /
Completed: "' -,Z-,aZ3 �"a tit. %5 ft. /fro ccp eoCr•—'
�5..Well Location; f 7.‘fr, !A�ti, c3a/r / - _i/
1 I M 0'�bi kl eo/@MA^' fr. j� fr. S L tC.4)Cs�+
Facility/OtvnorName Facility IDO(if opplicoblo) la 7ft. i/_n11t6 D/� / Q _fj
0 ft. ft. I�L �C7�l`�
/ S.8.5. ?f•(fiv'_Ra. t#tF p(Q1 5A ' MCA ft. ft.
r----: :f :� .:: --,: . -
Physical Address,City,and Zip/
//C 1�A RiL�SOCT 1.
a1.R RRMAR .r, .:. ..
County Parcel Identification No.(PIN) i r �O��
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: W ,,I,ZG
(if well field,one lot/long is sufficient). Cl2,Certification: C3,a+�t��.ty
t 5 ac, 8'3/ N pO6 a3' a 6 Wfizi /.7 .:66. �,.2' 4-2 o-Ztified Well Contractor i Date
G.Is(are)the well(s): crmauent or ❑Temporary '
By signing this form,I hereby cert t/tat the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0J00 or J5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the Well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair muter N2J remarks section or on the back of this fonn. 23.Site diagram or additional well'details: •
/ You may use the back of this page to.provide additional well site details or well
8.'Number of wells constructed: 0I di; construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the setae construction,you can
submit one fora. 24.Submittal Instructions:
9.Total well depth below land surface: 46 a r (ft) 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-38200'and 2 tQ/00') construction to the following:
l/^I
10.Static water level below top of casing: (f,) Division of Water Quality,Information Processing Unit, •
ifwaterlevel is above casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11,Borehole diameter: !0 (in.) 246.For Infection Wells: In addition to sending the form to the address in 24a
:`C
12.Well construction method; r,_ s/ above, also submit a copy of this form within 30 days of completion of well
T�t11�X construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 °/a' Method of test: A (r 24c.For Water Sunnly&Gcothcr m al Wells: In addition to sending the form to
' ' ``/,n� � the address(es)above, also submit one copy of this form within 30 days of
I3h.Disinfection type: Amount: TC-►f 3 completion of well construction to the county health department of the county
Vet, where constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality t)' Revised Jan.2013