GW1--07796_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:' ,
1.Well pntr�a/c�t/o1rpInformatio : di
1 J/R/1 r e - (14 0 11.!a�''` ''�� ''f'i �"1.17f @gfi'(Yi i�:�s l l 1 ittsd:`P �+;t�i Y,,Yy':ib�,�iii;•...`.?iui i%J.5',;,
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v OM TO I DESCRIPTION WellContmetorName - It. t(,
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• NC 11 Coonntttaotorr Certification Number `,S,f1:0 1g } IN INOVi 5' 14"ve1 15;(`, (ti`�il1 111rAlll tt u r'-'"''4t:::M
..(/'ter 11 1A)V G( /°a 6 , _1,-)te.. FROM TO •DIAMETER THICKNESS MATERIAL
rt. ft. •,.t a&in. 5.Q R -) PYG
Company Natde /Cl� /c*� Ifil #.1 Yl11Ai'''1`.s(MAR(tlliliititngia ) ' Slid!iii~<�i ii:=�.sC{::ri r
2.Well Construction Permit#: . f / 3 d 4 FROM TO 'DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,.Variance,etc.) -
Et. ft. in.
• fY. N. I In,
3.Well Use(check well use): • a' .;=;,tti }3, (s ;a u_ii i%s ,,4,,
17"iililc iY+1}�dl P izt/�iS 3?1t e ,'%?._, 'Ail;,i ' .Alll f fr _.,,faM,,,la
Water Supply Well: FROM - TO DIAMETER SLOT SIZE T'R CKNESS MATERIAL
12Agrioulturai 0Munielpal/Publio ft. ft. ' In.
Geothermal(Heating/Cooling Supply) 13Residestial Water Supply(single) ft. ff. , in.
Industrial/Commercial Residential Water Supply(shared) t ,.,. ti, r•+� >.x * ilattY ,�r.;g�?• gsrt:.il:.`•�.�'.:,1
Wt i�X81ibX3pl*� lir'''t'`r�ii`.,,t; �rl s•,n�3i� >z/t � f t i. �_w.; , :v1s '
Irrigation -- -- FROM TOK' ^ - `,,MATERIAL EMPLACEMENT METHOD&AMQUNr
Non-Water Supply Well: • rt. O,0 f. ,�t11 -2,0 k 15 G t$ A K.r CCtiI
Monitoring QRecovery ft. ft.
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Injection Well: . ft. ft.
0 Aquifer Recharge DoroundwaterRemediation ,� • , };,; }'4}',n a u� 'x ,t;`ra;: ,
41-!llr0 /.b a EPA4Z(i)'tM1I migi le;•. i:: ,:;4. ..a ail a igi s1itig e....'_2:s
Aquifer Storage and Recovery ' . DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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Aquifer Test . .\\ \1 r3 Stonnwater Drainage ft. ft, •
Bx erimental Technology ".‘' 0 Subsidence Control ft. ft.
DGeothennal(Closed Loop) \' OTracer
pi0PD Lee llefiitt90 ld'di itlfdtlallWifitiee,4igtliflls'hly:`1,sl';!'IU',ilu•:}.i++;:•';::•nit
FROM TO' DESCRIPTION(color,6ardaew,eol0rac&type,groin sire,etc.)
DGeothermal(Heating/Cooling
Rteturn) dOther(explain under#21 Remarks) R. 4-4 H, ),/r4I .G Q y
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4,Date Wells Com leted; !(�'c2�— Well ID# y'fa .Sf' rani te, /
ft. ft.
5a.We Location: •
�l � ��-Y 1/�!-� it. to Ti d, ,,i.
Facility/Owner Name •
Facility ION(If a piicable)
123 L-Br'Q er Ohie gal-• ft, ft.
/r DEC 0 ti 2023
Physical Address,City,rd Zip t A,(t ft. ft. y '^
County - Parcel Identifcation No.(PIN)- ; •
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:• •
Of well
field,one let/long is sufficient) (y I j 19 22.Certification: J —��
t"7`�� O N D l t t� w ��IS Lfi II--I—),
t•, Signature of Certified Well Contreotor t Da .
6.Ia(are)the weU(s) Permanent orTemporary - _ ..-
By-signing this form,1 hereby cart*that the wells)was(were)constructed In accordance
• 7.Is this a repair to an existing well: •DYes Or ENo with 1SANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
(f this is a repair,JNl out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
' repair under ti21 remarb section or on the back of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Cloned-Lon 4•eothermal Wells having the same You may use the back of this page to-provide additional well site details or well
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construction,.only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land-surfaee: " (iL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths(fdi8'erent(example-3@200''and 2®100) construction to the following:
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10.Static water level below top of casing: 4 0 (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 dlbmeler: /'l (in.) 24b.For Infection Wells: 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; �G �rY 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 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: a/r 24c.For Water Sunnly&Infection Wells: In addition to sending the form to
f`_ II t the address(es) above, also: submit one copy of this form within 30 days of
13b.Disinfection type: GN10 V•I rit.- Amount: ). &ups completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water;Resources
Revised 2-22-2016
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