GW1--02105_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Cnttractor Inforratio-ijctre J a-d e-1t_ V gKtNLS �Ne :; :.c.. .
FROM TO DESCRIPTION
Well Contractor Name • ft. fit.
2/6 "/5 4 ft. fit.
NLc,II Contractor Certification Number //�� �. ?15 D Ust!I)1t'CA`$U l i(lori'of{f try edkw$113)is0IZ3I)IN Itt(ft eq itcg0ib)
O S ( J/ V" �� PROM Dik ETER THiCKNE�SjS MATERIAL
Pi I v L{2Ci✓ fit. li .Yt:
drill gIeil(I )ComnyNa�fie '1"d? $Idy W X �Ulif P� :;:
2.Well Construction Permit#: / l / -FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)
ft, ft. • In.
ft. ft, In.
-
3.Well Use(check well use): <,r ,,�s r_
°fil.4st RN-tO;a t : r„i>k k.{'_,: ;;Its. a r,:::;;Z :-
�Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS „MATERIAL
1ii Agricultural DMunicipal/Public ft. ft. , in.
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. ,in. .
Industrial/Commercial DResidential Water Supply(shared) 4$i?dRmtk 4 r ;; » -°K= m;;:xV:. `: ,:;,ti .:: s;', ' , `.;
Irrigation FROM TO MATERRiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' U it. 1ii /-A Ile po u.r -J`/ g b�-�ly
Monitoring DRecovery ft. ft. v
infection Well; - R. -.;t.-
Aquifer Recharge a Groundwater Remediation `tl920ANf1ZGIii1VEliiPAQlfio(UtAPPiiafiileM ) ': : "'° ' "• "'
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test •``• D
Stormwater Drainage It. ft.
Experimental Technology ,.:4';•, DSubsidenceControl ft. ft. •[ .Geothermal(Closed Loop) OTracer 1'0hT11211sli151,Csrifl0:0s(ditrelf ifhflonalii ate ff leetj3eai>3C.:-:':6°:'" '
PROM TO DESCRIPTION(color,hardness,solUrack type,grain sloe,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ' b fit, /q,1 ft. 1SA.A-d J_G'et-� )/
4.Date Well(s)Coihh leted:-5'/e /L Well ID# • /Left. �J( Tt. r,L)A)'h
ft, i� ft. J
5a.Well Location:D��/ ���� l� r Facility 1DN(if applicable) ft. ft. `0 Lei�`fY+_D-. , ) -
Facility/Owner Name
' 17)-,C;25 )t.-/ kt A.. 0-, • • ft. f6 ,DPP, 0 < 2024
Physical Address,Citx,and Zip i y`,t
G=t�rt,�;;3;7(�
County Parcel Identification No,(PiN) ---'
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degreesi • '
(If well fief one Ist/long Iiksuifclent) r 22.Certification:
- J r 1/;Z-/ (U N 41` ', --.0 i w 2~�r,-'7
« ,Cum��c�l�.
Signaturaef Certified Well Contractor Date
6.Is(are)the well(s)0Permanent dr DTemporary
By signing this form.1 hereby cerl{fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: !Yes or 11)No ' f with 134 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
-- - -If this Is a repai lli-cut know.rweUcoilslruction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under N21 reinarlcc.rectlen or on the back ofthlsfbrnl. 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed=Loop Geothermalg the same You may use the back of this page to provide additional well site details or well
Wells havin
construction,only 1 OW-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 surface: •• . V 5 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f d(lferent-(example-3®200'and 1®i00') construction to the following:
10.Static water level below top of casing: 6 © (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 /4 (in., 24b.For Infection Wells:;In addition to sending the form to the address in 24a
12.Well construction method: r 0 a ry above,also submit one copy of this form within 30 days of completion of well
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 Mall Service Center,Raleigh,NC 27699-1636
I e
13a.Yield(gpm) ! 0 Method of test: 4.--1 r 24c.For Water Supply&Infection Wells: In addition to sending the form to
I ' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: (-Al
L+D r Amount: ot L,4--p S 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 i Resources
Revised 2-22-2016