GW1--07755_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 1
1.Well Co tractor Information:
- jd'1gfi A l l-r '� t x fYs t t<,'teYy�"'i.�i4#� '?�lft.:,r�•,xamfi;I,At.p4 x�,
A_r)^�i ,,4— eJ t HROM TO DESCRIPTION
• Well Contractor Name /� ft. ft.
21C4.5- l ft. ft. "
• NC oil Contactor Certification Number ammo I!?1D 13y o T. i�,,rov ,i13' o Sf atmat(i s•i ato t'�;z+': .<"t
�In ',}/j n I, ///'�, T'/���}', FROM TO DIAMETER THICKNESS MATERIAL
J�LX'` s C/!( .�/�C. �/Q, ,fir l`• ft. • ,•�•' ;I ��ao /-i ' ) YG •
Company Nee 3 — Ei':11!�sLl,lc'.15fic.`.C9/1t affidsl lni Slink"1 rkt•[�?'Sip fa4 '
MENN
2.Well Construction Permit#: YV RL [/ 6 D FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constmtion permits(Le.U1C,County,State,.Variance,etc.)
ft. ft. 111.
• ft. ft. ins
3.Well Use(check well use)s ,�,, : r�i,7f}; r �'"'�e '�'"'"�' "
1?1 ii8t i7 M' „ ._..?5�e. F -, !k _SYi'fi.4. .,e,>F'•,ffttl.'.!`iFtf'I`ls�,tJa!},.:s:lt}i�lr;r4ii..�u,
Water Supply Well: FROM TO • DIAMETER SLOT SiZE THICKNESS MATERIAL
,3Agrioultural QMunioipa1Publio ft. ft. 1 I to.
0Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft. { ,I In.
',lnduatriaUCommeroial �Residentlal Water Supply(shared) AlabfGp 'h Dy �� ent�= �
y an' Y e
31;•6ci/
Irrigation • FROM TO MATEqAL EMPLACEMENT METHOD&AMOUN'c
Non-Water Supply Well: - ___. 0 fa g d ft. b L:h l E?h;� . J 3 h of j4 --pD are 4. 1
CMonitering. ©Recovery • rt. N. v
Injection Well: ft. ft.
[Aquifer Recharge Qt3raundwater Remedlatioa /D , _ ( t ), .giii.i;vE;::Pik.a4Yl:itvi''4. t Lir,.s A'>�:0r4ii4
Aquifer Storage and Recovery ' . y 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
•
Aquifer Test r `. •• DStormwater Drainage • 11, ft.'.,,
0Bxporimental Technology 's•"ti',‘' QSubsidence Control ft. ft.I.
,ocotherma
DL(Closed Loop) OTracer V1�0"1741IilLt G OC (MO)1f0iltiifd#Hill 't1 4'hos. Ali')1Ndy}. ::Y »;bk,,.).,r.r>:�iK:<•
L. , FROM TO' b DESCRIPTION(color,6ardnet4,oltfrock type,Grain etee,etc.)
r}t3eothermal(Heating/Cooling Return)/ no qb mother(explain under#21 Remarks) 1t. ft, ;ri;rf .SG GI ay
4.Date Well(s)Completed:` )/•—)4-23 Well I it. 36 �. 1.4 rim;tom
5a,'Welll Location:r ft. rL i'
l 1 !�kit �o n , ft. It. -. . , -{ ',R i N
Facility/Owner Name Facility IDN(lfapplicable) k' ft'I '
a2' -4 j- `C kit.Ydcit LK: L•o j' 4
ft. ft.r , J E C J j 71123
ft. rt.', trif.j- - ...<,.,
Pbyeiv ddrosa,City,and Zi � ., _t t �Y!. .7'F.. ..;;�y;,,-,.r •}.�,y^,`','.t
a -yf.s i�fr':•1•+(:,i tx� N�4't:c;,�y.l th115.e. i ;;i�i,.: 0j iy.G•'•st';�I4•a• ia.•...i::.i=•.
County
Parcel Identification No,(PIN).s .
SINLatitude and longitude i6 degrees/minutes/seconds or decimal degrees:• ' '
•
• (if well field,one let/long is sufficient) 22.Certification:
3COS6D3 N -Qj , gq a 15" W (�� //-
Stgnattue of Certified Well Contraotor Date
6.Is(are)the wells) Permaaerit ' oarTemporary - - v
- - -- - - _ -• � -" ;By signing ihis form,I hereby corethat.rhe.weli(s)_was.(wart)constructed in accordance
7.Is this a repair to an existing well: DYes or DINo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well"Cons:ruction Standards and that a
If this Is a repair,Jill out known welLconstruatton Information and explain the nature tithe copy eta record has been provided to the wall owner.
• ,
repair under 1131 remarks section or on iha back of this form.- - 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-I oo -eothermal Wells having the same You may use the back of this page to provide additional well site details or well
p R construction details. You may also attach additional:pages If necessary.
coashuctioa,only 1 OW-1 is needed; Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface; . (ft.) 24a,For All Wells: Subinit this form within 30 days of completion of well
For multiple.wells list all depths(fd()7erent(example-3@200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:• 11 (ft.) Division of Water Resources,Information Processing Unit,
(f water level is above basing,use"+"
1617 MaUlService Center,-Raleigh,NC 27699-1617
11.Borehole diaine er: r (ins) 24b.For Infection Well4:;In addition to sending the form to•the address in 24a
, In above,also'submit ono copy of this form within 30 days of completion of well
12.Well construction method: 1" 6�0r y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) . Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MaIi Service Center,Raleigh,NC 27699-1636
i
/i2Method of test; t2/ 11 24c.For Water Sunnly&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
Amount: A.L'�/,4" completion of well conitruotion to the county health department of the county
13b.Disinfection type; where oonstmoted.
Form OW-1 North Carolina Department ofl3nvironmental Quality-Division of Wet®r Resources
• Revised 2-22 201E