HomeMy WebLinkAboutGW1--07756_Well Construction - GW1_20231201 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ' •
1.We ontractorA � Informs on: r/ p - ! 7� t
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Leib•OM TO DESCRIPTION
Well Contractor Name lJ ft, ft. I I
• NC W 11 Contractor Certification Number ��j (�YjtARg f)i({I(�eftgt�l() i(i3vel)fl),°1t1Ii11' i ( l ]1Sllllb)n�l :'_ "'•: :'t
// r (1 }� PROM TfO� DIAMETER THICKNESS MATERIAL
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CompanyNeme/ J }'ir 1. 1 c.t-t. ,'
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2,Well Construction Permit#: 1/4 &.i / L/ v 0 / ✓ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.Ul ,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): + �ot f<. ft.
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Water Supply Wall: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrioultural DMunioipal/Publio ft. ft. 1 in.
Geothermal(Heating/Cooling Supply) igResidential Water Supply(single) ft, g, 1 to,
Industrial/Commercial DResidential Water Supply(shared) youc>;tOrlN :gilli m.i.`e ;'a'a 5}M 1`'f3,=1 W^yN f IBM'"'Yi.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Zb fw ben ten/1-E. )A b a'm—/D 1.(-Ycl
Monitoring DRecovery • ft.- ft. - `�J! •
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remedlation �,Ey.;, ,, ;, n P;,
'1'191:1SANDIG �klAVIC3f$iA5Sp:1a48 ;A:r�,�yi .: ��fiaz„`ic:i',�s;;,,r.,; M'44.'�. �,
Aquifer Storage and Recovery ' ' DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test , ‘.`. DStormwater Drainage • ft, ft,
Experimental Technology :•<c .,',..• DSubsidence Control ft. ft. •
Geothermal(Closed Loop) DTraoer J 6Ftlllr fRdL`g'Cs",IIO:G{t(aftndl fdid'dill'dniFifi lfi eecl 4*-)C:'i rsl':" i`; )1i 3:>?:ii;Xf`
FROM TO' DESCRIPTION(calor,6ordneu,relltrock typell grain size,etc.)
Geothermal(Heating/Cooling Return) IN Other(explain under#21 Remarks) /7 ,/ it. C//'GZ 1�L I
4.Date Well(s)Completed: i�"3 .0 It.` Well ID# li 5'f• 20J1t. ' Gl Y Afr %7fi
ft. ft. i J ~. .:.
5a.`�ell Location: •
/11i(�iralAs vt
es H. ft. �; ..F - '
Facility/Owner Name Facility IDH(if applicable) ft. ft. f r r 0 1
: . Lf/g 6 gills is Creel Rd,
ft, ft. 2023
Physics Address ity,and Zi '_. 'I 1'r
/ r 1 i;'ij�';R/Mala v'%"1l•. iAl..i: <.:.44 =r#?+.,,,01,.,:,0,:t:r ix5!:'!4o,. .':''[ ::`=:+•>,:,
County Parcel identification No.(PIN) . „ •
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5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:• '
(if well field,one let
l/long is sufficient) �J�j ? / 22.Ce cation' /7y--:
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36' , � l N —Z5 0�, f Q 9 r� CD W �- ��'` I l-of y7
i Signature of Certified Well Contractor ( Date
6.Is(are)the well(s)�Permenent ' or�OTemporary v
Sy signing this form,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction information and explain the nature of the copy of thls record has been provided to the well owner.
repair under 1021 remarks section or on the back of this form.- 23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed-Lao Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
P R erma
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBBR of wells construction details. You may also attach additional'pages if necessary.
. drilled: ¢UBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a6-- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
• For multiple.wells list all depths(f dWerent(example-3Qa 200'and 2@l00) construction to the following I;
10.Static water level below top of casing:' . 1('' (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 Wens: 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: • )`/)tom y construction to the following:
f
(i.e.auger,rotary,cable,direct push,etc.) / I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i 1636 Mail Service Center,Raleigh,NC 27699-1636
�0 Method of test: 24c.For Water Sunnly&Ini!ction 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
i ('�l,L/)s completion of well construction to the county health department of the county
13b.Disinfection type: A/!DY/Y( °V Amount: `-'--' where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
1Revised 2-22-2016
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