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Home My WebLink AboutGW1--07757_Well Construction - GW1_20231201 • 'ZWELL CONSTRUCTION RECORD(GW 1) For Internal Use Only; 1.Well Coatra¢tor/I�nfor//m/a/�H�jont 1 • DGL1�l m� _ - !§�Ab1'�/�1?111��111;51Ir;'.��;�DEc�rca�tYs�X��t�.��d's'1(�:,r��:s;t�i#�( .>..,.��.,,;r FROM TO WelfConlraotorName ft. ft. • NC Well Contractor Cerilfloat on Number ;•`vlllili(tJi)Er'' T. ((R{! 'r 0t)L10 111t { ' lit, �� FROM TO 1. • DIAMETER THICKNESS MATERIAL. //�� ' I C�G(Nam 5 i1 �--1' �1tIn- b/ 1 / ft. Jg •"n. . ,/ n. f 1Q Z t Company Nam • 11di1)1bi1#0 C 1' R1/144ipIC@ tb Ii41 1'IBob)i?' i&fiG 811.if.ifOR ug'+' '-f: S GG4.2' - J\ 4 � FROM TO I. DIAMETER THICKNESS MATERIAL. 2.Well Construction Permit#: `/ ft. f, hi. . List all applicable well construction permits(I.e.UIC,County,Stare,.Variance,etc,) In 3.Well Use(check well use): 7 ��f!4rSt; `:' i474h��i!(' litAYif't3a4t)�jstilpltw.'''t}}dF;'4zi rift4•.( 011 1fK'Inx" Water Supply Well: 111 FROM TO 1 DIAMETER SLOT SIZE TH' KNESS MA'I1 RML Agdoultural QMunioipal/Publio ft. ft. ; 1 In, Geothermal(lieating/Cooling Supply) geResidential Water Supply(single) ft. ft. I I lo. Industrial/Commercial [, Residential Water Supply(shared) cue ;-,}, ,,-.-;itna0,4;44 ioNgym Itt#kf 'r j'r%;rii fmiE td z .- Irrigation-_ NT FROM TO MATERIAL EMPLACEME METHOD&AMOUN Non-Water Supply Well: - .� ft. go ft• b e nlfie /4 Ads Ito ti-reJ Monitoring, II Recovery • • ft. ft. Injection Well: ft. it. Aquifer Recharge pGroundwater Remediation }t t j p' 1($t�q 0tb)).":'•i i?;y�v`'r t';'a��a2Ya4t l�+ai:i }r`w a tc f`Q, 1VISMIB7A1tA. EMPLACEMENT METHOD Aquifer Storage and ReooWcry ' QSalinity Harrier FROM TO MATERIAL Aquifer Test : N. N. `' QStonnwater Drainage • ft. tt. • Experimental Teohnolo ',.'::,.. 0SubsidenceControl It. n'' yl afi>oi�*Oli 4+g( bl/Ndati1K#bOISICifrYi )i ,ly,.l,.. +h;;Yis:'•:).0:), Geothermal(Closed Loop)`' OTracerFROM TO' h . DESCRIPTION(color,hardo r,ealUrodc type:groin etxa ain') Geothermal(Heating/Cooling Return) !DaherdOther(explain under#21 Remarks) 6 I. 10 9 ft. V i,. V e-) I c Jay ' 4,Date Well(s),Completed: /0 .J a- Well ID# 'f /a ft' L/6�1: r,it-nil'i ft. ft. L So.Well Location: • 145541 tt. Ift. „r .` r,r: f7-,:7.-N Facility/OwnatNeme Facility IDN(!f ap rt. itt. - �.�, rug•it,_„ �a T. a..,; plicable)�b ft. art. DEC 1) S 9n�� • . 1l FA Omer Jf14)15-1;id I ft, ill. Ph a I Addros,City,and Zlp °LY a-K.. �-rms v x;;, n +?,i..i.^:'4 t"'y`i: }lv'. "!r : ;.;,t 5 y p / ) l'•.?di?1i711f6! ys•urr?:'3 '.,,va�r':�r 4�t;n•.:,...r,,.., 1...v...,[:?.t• ., . IC County Parcel Identification No.no_ .. - 5b.Latitude and longitude ih degrees/minutes/seconds or decimal degrees:• • (Ifwell field,one lat/long is sufficient) 22.Certification: f 8igasturo of Certified Well Coatreotor Date . a well(e) Permanent ' o� QTomporary_ - - 6 Is( re)the By signing this form,I hereby cer*that the welf(s)was(were)constructed to accords- 7.Is this a repair to an existing well: DYes or 11)No with 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and tin Jr this is a repair,fill out known well construction Information and explain the nature tithe copy of this record has been provided to the well owner. repair under i121 remark,section or on the back of this form. 23.Site diagram or additional well details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or v. construction details. You may also attach addltional'pagu:s If necessary. • construction,only 1 OW-1 is Hooded, Indicate TOTAL NUMBBR of wells ��TTAI,INS�'RiJC�'IONS • drilled: j� 9.Total well depth below land surface: -I (2' (it.) 24a. For MI Wells:1: Submit this form within 30 days of completion of v For multiple,wells list all depths(fdWeerenf(example•3(0200'and 2@100' construction to the following: I, I 10.Static water level below top of casing:' d (ft.) Division of?Water Resources,Information Processing Unit, If water levelly above basing,use"++" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (p,'- (In.) 24b.For Infection We l ; In addition to sending the form to-the address in above,also-submit one;copy of this form within 30 days of completion of v 12.Well construction method: re)fa-r y construction to the fol`owing: (IA auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection'Control Program, FOR WATER SUPPLY WELLS ONLY: i - 1636 Mail Service Center,Raleigh,NC 27699-1636 Method of test: A-1 i/ 24c.l+or Water Sunnly&Infection Wells: In addition to sending the fom 13a.Yield(gpm) I the address(es) above,'also submit one copy of this form within 30 days Amount: C,u..,�_ completion of well donstruotion to the county health department of the cov 13b,Disinfection type: tyY I n • where oonetruoted. 1 . • Form OW-I North Carolina Department of Environmental Quality-Division of Water a ter Resources.. Revised 2-224 _