GW1--02402_Well Construction - GW1_20240423

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well tractor Inf rmatl n: t i
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Q ( FROM DESCRIPTION I
Well Contractor Name R. ft.
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NC Wel Contractor Certification Number , /.��� ^ /�,/V r =t�ltt�J0Uh1�tYG'r1;4 ;(fir( DIAMETER )�pki9
H CKNES(S n�IIMATERIAL
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Company Namq/ •j� •;11 ER AI l FRO TO DIAMETER i Ided THICKNESS MATERIAL
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2.Well Construction Permit II; Rf C%
ft, ft. i0'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In..
3.Well Use(check well use): • :., ` ];f_• ,-'�i* any :3 i:, .,; i•.ss� ,�.;;,,_,: :•-.;,::,...'4?.-r..: ;.';-" '•.... .
Water Supply Well: ••OM DIAMETER SLOT SIZE •THICKNESS MATERIAL
ill Agricultural D MunioipaVPublic ft. ft, In. I',;� In.Geothermal(Heating/Cooling Supply) IMResidential Water Supply(single) ft. ft. I i • t,. .. .
[Residential Water Supply(shared) < :,`r s•o,1e cogr'r:F.. A.4 .,•ors Aiziii y ek!i'>?s.16*.;:1:,i..�xe ai' l•v
�I ri triaUCommercial pp y
PROM TO MATERIAL I EMPLACEM' TMETHOD&AMOUNT
�Irr-Wain © ft. d rt. .4en en/ I our• 42. 6 5
Non Water Supply Well: R.Monitoring _ -- 0 Recove - - ft.
Injection Well: ft. ".•
Brud;tPeInedlallohl
:)PAquiferStoragndRecoyarrier «, ft. ;
�:" Stormwater Drainage , •
Aquifer Test ft, ft.
'• Subsidence Control
III Experimental r2,ga3-E p_•o e �11i�• jrei o"t ea dal;:;,•.W:`:*."_ ',.c....
jiGeothermal(Closed Loop) Tracer 1 . FROM TO
DESCRIPTION color hardness loll/rock .a :rain size etc.
Geothermal(Heating/Cooling Return)".;'Other(explain under#21 Remarks) , ft, lag q «. [
We11ID# 'ID ft' D.Ij:ft• a j^�LIl! 64.Date Well(s)Coihpleted: ._. ft, It. -- -
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Sa•Well Location: P t' Y°'
rt. «• l• ��'"'°�1'-f�'fir �.'° '�•--'�LC�C�--cJl�-�'� K. rt. ft. , .. '"- "Fit ity ID#(if applicable)
Facility/OwnerNema ft, ft. .
Physical Address,Cit,and Zip iSt 9 q ft.ry .•,&s;:;^. ft.(' u... :;':} '
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C.- D
Parcel IdentlflcationNo.(PIN) '. I
County
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:'• 22,Certification:(If well field,one latliong Is sufficient) • I •
i lSignature oCCartiflad Well Contractor
I Dale
6.Is(are)the wells) Permanent Or Temporary ,By signing this form,I hereby cerg&that the well(s)was(were)constructed in accordance
�` with 13A NCAC 02C.0100 or 13A NCAC 01C.0300 Well Consh•uc!!on Standards and that a
7.Is this a repair to ant existing wells on lit br l6 .�No - copy of this record has been provided to the'well owner.
(Jddsls a repair,JIlLaur known wall8opslructlon hi%rmbtlwt and explain the mantra ojrlio 23.Site diagram or additional well details: •
repair under N11 reinarkrsectlon or on the back of lids form.
You may use the back of this page to provide additional well site details or well
8.For Gecprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,ion,only 1 OW-1 is needed. Ihdloate TOTAL NUMBER of wells QiaMITTAL INSTRUCF1ONS
dril
led:_.-----'
9,r a multiple
wellw depth below land surface:
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For roulrfple wells list all depths(f d(Q'ereur(example-3®200'and 1(g100') construction to the following:
7 (ft.) Division of Water ResourceeiInformatlon Processing Unit,
((watterr level
Is above casing,use"+"
(0• e water level below top of casing: 1617 Mall Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Injection We111: In addition Lo sending the form to the address in 24a
11.Borehole diameter: _ _ above,also submit one copy of this'fgr'm within 30 days of completion of well
12.Well construction.method: YI� 0.Y ! construction to the following:
er,rote ,ceblo,direct push,etc.) • Division of Water Resources,Underground Injection
ion27 Control Program,
(i.e.aug , ry
•
• 1636 Mall Service Center,Raleigh,FOR WATER SUPPLY WELLS ONLY: : Qrntectlon : In addition to sending the form
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13a.Yield(gpm) Method of test: �) /� 24c.F ><the address(es) above, also submit tone copy of this form within daysrto
f
G k- S completion of well construction to the county health department of the county
13g,Disinfection type: ., 0�) Amount: -where constructed.
North Carolina Department of Environmental Quality•Division of water Resources
Revised 2.22.2016
Form GW1 .
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