GW1--06766_Well Construction - GW1_20231023

I
WELL CONSTRUCTION RECORD
This form can be used for single or multiple Wells For internal Use ONLY:
1.Well Contractor Information:� I
i '�� 1'�.. a"`�-t 1 5 •'•14.:WATER•ZONES,::;....;•:.•r.}. is-,;': Ea.a • '':,:,i::+;a••;•": rr ::_
i'i ••...,.: ... ,J.
FROM TO DESCRIPTION • "'
Well Contractor Name D ft 30 ft 4 A
c:Za38 — 1A., 34kft. .44/o ft. /_E 6AL
tNC Well Contractor C cation Numyer :;15:OUTER:CASING.Vor multi•cased wllls)'ORL•1NLR;(ff op'lirithIc)~ •...
WC116¢ K MP WEI i7 1 l t FRO ft: 1.4 6 }t, { DIAf t R i. THICKNESS MDATERIAL
Company Name 1 �77 �D4 Z .. vc
T
C� 3 €16::INNER'CASING'OR'TURING:(geotlice il•dosed-loop)';:^,5.•:'':;
2.Well Construction Permit ti: FROM TO DKAa1LTTE THICKNESS a7ATEtrIAL'
List all applicable wall construction permits tie.County,Stare,Parlance,etc.) It. ft. In.
3.Well Use(check well use): t• ft. In
Water Supply Wcli: :;.17:SCREEN;> ::•1, , ,,...;.• .,,, , :;, :,.... ....
FROM TO - DLIMBTE SLOT SIZE THICKNESS MATERIAL•.•••DAgricultural ❑Mun�unicipal/Public R. ft. m
❑Geothermal(Heating/Cooling Supply) �ftesidential Water Supply(single) ft• ft. in
❑industrial/Commercial ❑Residential Water Supply(shared)
'.18i_GROUT 'S;'�.�:ti•i..... ...
❑hrigalion FROM TO MATERIAL' E^ CEMENT hIETHU 8b1
0A0UNT,
Non�VaterSupply�VelL O ft' ZLI� ft.4Ptf Jt/ T y�,D d SO-GAL.
❑Monitoring ❑Recovery ft. ft• L► _ ,` Ii� !it '`
Injection Well: eV"T l���6P
ft. fr.
❑Aquifer Recharge ❑Groundwater Remedialion ..]9 SAND/GRAVELTA:CIG(ifnpplicahlc);;_--;•! +,r;:if'. •,•:;..:,;,;,, ,.
❑Aquifer Storage and Recove PROM TO 11fATERKAL •4' ❑Salinig HarrierEMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr.
t R.
DExperimentai Technology ❑Subsidence Control ft. ft.
'.20DRILLING:LOG'•(attrichuaditionaIabeots'ifribccssuiy)': .,.,,;,•, ;:.:•;: ., ..•ity;,; ,
OGeothennal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return FROM TO DESCRIPTION(color,bantams,rollback type,grain size,etc.)
/ ) ❑Other(explain under 1/21 Remarks) 0 ft, .2•.� ft. BM Kk.a V RioC e. •
4.Date Wells)Completed: 5O ' -Z 023 Oa 0 ft. 25- ft. a�L j eb�`
5.Well Location: oG ft. 6 it.
e—k�b2� .�'}el Wl5 ft. ,.h ft- eri3ci 7/ J
Focility/OWearName Facility I ft. it. . t�,f
1, Dt(if
I� G/{D/i _
Physical AddressC1Y� f!t Rdl(C �� ft. ft. 1 •- °_`-'i L.G. :Ar' :Iy
�5 fa a)t�y 1 U' S 1 `ity,and Zip
2I:ItEMA HS o :• •:IF. •. 5 r . :'+e.`;• ,023
County Parcel Identification No.(PIN) t^`^•�Tn 3'i^, ta.•
1 :y:'S::',s itii
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
p' !Yf �
Orwell field,one lat/long is sufficient) 22.Certification:
3sm9 ff /-)
i_z_z„,..;;;"i
6.Is(are)the well(s): flilhermanent or ❑Temporary1°lure ofCetttfied*ell Contractor Data
By signing this form,I hereby cars that t(ie well(s)was(I ere)constructed in accordance
7.Is this a repair to an existing well: ❑Yts or with ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Intl Construction Standards and that a
If this Is a repair,fill ors known wen construction t fornratlou and explain the nature oldie °opy of this record has bean provided to the Well'owner.
repair under 021 renwrkr section or on the back of!his fors,.
��//� 23.Site diagram or additional well details: •
8.•Numbel•ofwells constructed: ®6ti[: You may use the back of this page to.Provide additional well site details or well
For multiple Infection or non-uatersupp/y wells ONLY with the same construction,you can
construction details. You may also attach additional pages if necessary.
srrbrn/raneforur. 24.Submittal Instructions: I
9.Total well depth below land surface: 4-TO' (ft,) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths lfdi,Qcrent(example.3Q200'and 2 100
Cal 9 construction to the following:
10.Static water level below top of casing: CI 0 I. (ft.) Division of Water Quality,Information Processing Unit,
Ifuarer level Is above casing,tyre"+^// 1617 Mail Service Cente`,Raleigh,NC 27699-1617
11.Borehole diameter: G. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: moo. arY above, also submit a copy of this fort within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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) t(0Method of test: Air 24c.For Water Supply&Geothermal'Wells: In addition to sending the form to
Ti 1_fe1._ the address(es) above, also submit oneicopy of this form within 30 days of
, 13b.Disinfection type: ZS Amount: ,..f $ 174 r completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department epartmcnt of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013