GW1--00168_Well Construction - GW1_20231229

WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only: •
1.Well Co tractor Info
rmation:
.\ -� -
GUY'r e- 1} f G '�1 l now yam=x!1Jt f�+ltfttYYf.:;i$i xl:iksagttx, fii n`ta,t f>=i ..
- _ FROM TOI I DESCRIPTION
Well Contractor Name \ ft. I I ft.
5�5 ft. 6 1 fA
• NC Well ConWetorCertlRoetionNumber V�1tilk((1_Ii 'R 'Nov tall.tEiifdov.$ltli)tdlt�tmart ll lirif)!u �r�:
FROM TOI ! 7 °'
TC �m �A P .L`u' I . spml1do 11ti6Yli'eitifthl ' 918o0)i 5�t$tka#Viki.i"�.i?'i
�� q / FROM TO f I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. : ft. ln,
List all applicable well construction permits(Le.WC,County,State,Variance,etc.)
• ft. p ft. �,
3.Well Use(check well use)i r"i
Water Supply Wells )>21hi(So1 1i (t.00 ir' v:� �:;�ia `d "tr�SsJk}kg�POs is;tI{i}?0##'a£+lighlfct,�.:,tkt
FROM TO i DIAMETER SLOT SIZE THICKNESS MATI
DAgrioultural Di MunioipalPublio ft. I fi. in.
DOeothemtal(Heating/Cooling Supply) ppResldontial Water Supply(single) ft. I N' in,
Dlndustrial/Commorcfai 0Residentla1 Water Supply(shared) Rig b p ,vlshositrv{;u ,A.0 re.A f ad l °(;k' �x ;��y:; °fit
f irciRatlon FROM . TO'' MATERIAL EMP CE METHOD&i
ff
Non-Water Supply Well: • O 67.0 ft. b 8/2gv E jil ,b a_as'--o w s
DMonitoring .1*Recovery ' - ft. H. - • --, -. .. -
Injection Well: ft. ft.
[Aquifer Recharge Doroundwater Remediatlon ,f9H3, %Q y% i s��r:v'`zi d?r`r:ti}ilk!+"s.'� ;d<i"is
DAquifer Storage and Recovery ' ' DSalinity Barrier . FROM TO I MATERIAL EMPLACEMENT METH
DAquifer Test ``.: ' \ \`. DStormwater Drainage ft, ft, .
DBxperimentalTcchnoldgy ',:•..` 1;.�• DSubsidenceControl ft. ; ft.
Daeothermal(Closed Loop) • III Tracer • Min • Do:G(a'ad fd'diflii8 Iil'8'+ t i'i6Yfec i ii3')l h�[{il�,IYrtl0iry .
FROM TO'1 DESCRIPTION(color,bareness,wllirock type,strain d
( • nGeothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) © «. / H, �l' Sa / G(Gi y
t /
4.Date Well(s)Completed; '/9`�2 3 Well ID# /3 O ra6 >^� te_,
5a.W U Lo atlons i H. II ft. —^
Q V)i1 C.-YVU'(e -,4h' r,(as /iomeP/Gt�,o, ft, I, ft. , , t,,,o ;. .:t ra= a,.
Facility/Owner Name ( FacilitylDO if applicable) ft, I, ft. r rn
er is�� f I ft. D' 1. '� i, £ 2J
• J ft.. ! , ib Slioi-i,•.:,:c"''n Pr:^•no.:0 i-7 I S .�
Phyaloa�ddro�,Clty,and Zip
Vv „ r t5t hFln � :: .
/]/� l�l/.ti? +��i+•1iFiSbc,�.S':.ti :l"^�,' :il nisi' t:�t ;a! +lii,:+�y.('.t)c:, ir;:<=;y.is
a
County Parcel ldentifioa11onNo.(PIN) ,. - '• -
•
5b.Latitude and longitude iil degrees/minutes/seconds or decimal degrees;• ' • • '
(If well field,one 1at/long is sufficient) 22.Certifications; •
3�,34167 N — '2 19gA w .��v 4 _•• �i- 1-z
_Signature of Certified Well Contractor Date
6.Is(are)the well(s)O1Permanent ' oLr'DTemporary . I
By signing this fonn thereby certt/y that the walls)was(were)constructed in,
7.Is this a repair to an existing well: DYes or IiiiNo with 154-NCAC 02C.0100 or 154 NCAC•OZC.0200 Well Construction Standards
,(fthis Is a repair, lli dut known well construction information and explain the nature of the copy of this-record has been provided to the well owner.
• repair under H1)remarks section or on the bank of th&form. 23.Site diagram or additional well detaUst
You may use tho back of this page to provide additional wen alto dotal
8.For Geoprobe/DPT or Closed•LeondIcate rural Wells having the same construction details. You may also attach additional'pages If necessary.
construction,only I OW-1 is needed; Indicate TOTALNUMBSR of wells '
. drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer i.
(ft.) 24a.For MI WeUst Submit this form within 30 days of completio
• For multiple.wells list all depths If difierent(example.3 00'and 2®100) construction to the following:
10.Static water level below top of casing; ' 0 (ft) Division of Water Resources,Information Processing Unit,
If water level is above dosink,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Boreholediaineters C (in)) 24b.Tor Inlecti n Welia: In addition to sending the form to-the addr
above,also•submit one copy of this form within 30 days of completit
12.Well construction method: • I' I u-1`y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Pr(
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mail Service Center,Raleigh,NC 27699.1636 •
. Method of tests Q-1 V' 24c.Tor Water SunalvJc Infection Wells: In addition to sending tl
13a.Yield(gpm) the address(ea) above, also submit one copy of this form within 3
13b.Disinfection types /�'l-I 0 it el Q-•Amounts 2- G U— completion of well construction to the county health department of t
where constructed.
Form OW-I North Carolina Department of 13nvironmenta Quality-Division]f Water Resources
Revise•