GW1--03002_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information: •
&ctrrctf Ca d,.e,-t-1" vvAl l wa �:-k -au�� ""�:;-,6.- . ,
WeIIConlraolorNamo . FROM TO ft, ft'
g5g5;4 ft, rt.
NC Well Connector Certification Number 0:A'+, , A , ( t! I C :.d(Alfgfe sfjl)Q} (Ijjpti;11Utl19)%.::::.• :
r d FROM TOO DI.115
E GR S}1Sf1 MATERIAL
�L`� O�h �[I HL� �r1• ft, 7 ft, i..) In, /n
Company me •i 1i c� tit 'a o (11E'(a nit
S11 I .O(,IOI PROM TO DINA,1P. ER
Witirainlilli
2.Well Construction Permit#: W� ft. ft, i"�
Ell
List all applicable well construction permits(l.e.UIC County,State,Variance,etc.) _
ft' ft. in,
3.Well Use(check well use): U: .t:y" ';•�,»ft;;){;� �S,fi,Yjt,,.:..y`�+•y,..y;:,;,.i ;..•�;�,!•jtia:.r(i:.r•:<, .. .
fh Sdif4 �w31$1.V s s
Water Supply Well: FROM TO DI METE 8LO 8 ZE THICKNESS MATERIAL
Agricultural DMunlolpavPubllo n, ft, In,
Geothermal(Heating/Cooling Supply) tRosidential Water Supply(single) ft, ft. In,
IndustriaUCommercial DResldential Water Supply(shared) t j w ;;(�; �7:r •+.,.;'i-'. .!:"':4'x°;,.,',, ::,o..:'<,; .'..'
�1�;iEbfi�� i�i�,s:�Js'(;;f ;i;Y%,r h,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' r,/,Q It' IM47t- 1-. 10 i G�S
Monitoring ;Recovery , ft. it,
Injection Well: ft, ft'
Aquifer Recharge ]Groundwater Remedletion ;19.),S T1f1/, It 14A $(Ifalla0iiie.;;4 .:S:.t :'!:k°.'.(;''r';,:.. :'.'• :
Aquifer Storage and Recovery1' OSaiinity Barrier FROM To MA'TFRIAL
•MPLACEMENT METHOD
ft,AquiferTest ' � fft,StormwatorDrainage _
Experimental Technology �.,�• 0 Subsidence Control
-�tTrecer l:i 0a4t1016101 ,q;gi(g'ft pft`a11,1.'y 'et t t i••0 'hi):3;.:,.,;ri:%-;
Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardnert,tolVrork type,grate size,etc.)
Geothermal(Heating/Cooling Return) (f Other(explain under#2I Remarks) 0 ft, �`+-�7/oy ft, /'A a v l
4.Date Well(s)Corklleted:s9 Jr J_� f Well ID# � ' rt "1/t/ f t 1�, -�-'1 7 C
ft, I.
.
58,Well Location; • ft, I.
1or•y C'mknso✓► rt. e
Fnollity/ weer Name Facility ID#(if applicable)
•
•
ft. ft'
' II6 In 5pirct,+an P idc►,t1 ft, ft,
Phyplcal Addrete Clay and Zip 0 Fi 1'� fit- ` ;�,-:. ,T:, . :,y,: ••
It/'1` ��h �d s�''::1-:r:��7; ';: .,.me:: +,:
County +� Parcel Identification No,(PIN) -.,
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreeai 22 Certification:
(If well field,one let/long Is aufriolont) /
35 ,u 8'2 N — 81.1 V1 g° W -../ .51 � -
� 3lgnatura o��ertitled Woll Contraatot i Date
6.Is(are)the well(s) Permanent dr Temporary
By signing this form,/hereby cer'(1y that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or igiNo . with ISA NCAC 02C,0I00 or ISA NCAC 02C,0200 Well Construction Standards mid That a
ITthls is a repair,fill out known well construction Information and explain the nature oldie
cope of this record has been provided to the well owner.
repair under#2)reinarks-t ctlan or on the back of lists form. 23.Site diagram or additlontd well details:
You may use the back of this imp to provide additional well site details or well
8,For Geoprobe(DPT or Closed-l:oop'Geothermal Wells having the same construction details, You may also attach additional pages if necessary.
construction,only l OW-1 is needed, Ihdloate TOTAL NUMBER of wells SUBMITTAL INSTRUCTI(�!$
drilled: �y
9.Total well depth below land surfacer qo5 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For+nnitlple welts/1st all depths If different(example.3@200'and 2@100) construction to the following:
10,Static water level below top of casing: ab 0 (ft.) Division of Water Resources,Information Processing Unit,
((water level Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11,Borehole diameter; 6 (in.) 24b.For Infection Wells: In addition to sending
form
t0
00mp address
of in 24a
1 • above,also submit one copy of this form 30 days
ell
12,Well construction method;
A01 ary construction to the following:
(i.e.auger,rotary,cable,direot push,etc,) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
//�� 24c,For Water .021.Y� n W
-haeljoalla; In addition to sending the form to
13a.Yield(gpm) Ll Method of test: t the address(es) also submit ono copy of this form within 30 days of
Ckivri '1 Amount t! completion of well construction to the county health department of the county
13b,Disinfection type: where constructed,
Revised 2.22.2016
Form QW•I North Carolina Department of Bnvlronmental Quality-Division of Water Roe mimes