GW1--03530_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only; _ 4
1.Well Contractor Inferr//QJlatlons •
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Well Centrrolor Name 0 FROM TO DESCRIPIDN
ft, ft,(-1636 A
NC Well Conneolor Certification Number ' ".0tAMMt$))Vtl;(tfig''`'J}ttr4giliV►lit:0 ,'t1t)iNgkf{tYNkp11ci{HIW::. .
`^"x' I Yel l Cf YLd Po Q wit FROM TO DIAMETER THICKNESS MATERIAL
Company Namo I ft. g O re' 1473 in, 50 Q2 1 pv
1 ��;),W#, N iW. 'AMOR OR livp:Tib'(Htftr lt7i l ed�(`s>i21yY4'�.,,;j',;v,?;."_x,.°:,.
2.Well Construction Permit#: 17 1373 FROM TO DIAMPan THICKNEes _ MATERIAL
List all applicable well construction permits(I,e.UIC,County,State,Variance,etc) ft, fL In.
3.Well Use(check well use); ft, It. In.
Water Supply Well: f e.Q i`r)it*o'' ti;ii,;SliiscI; ' 'i:'�;:};;,r;i::,',,•;:. .: ;4 .;,t: .
FROM TO DIAMETER._ SLOT SIZE THICKNESS MATERIAL
Agrloullural DMunielpal/Public It, It, In.
Geothermal(Heating/Cooling Supply) tRosidontial Water Supply(single) rL ft. n,
Industr aUCommercial [;, Residential Water Supply(shared) yr r i a Div•. 5 t�, {
{31siogov A.mpi:t*,:�T' lr'•t/t:: ri, �i'�:-Ni-.ry L .i i i `4,),, .{ $ ;..'.r�i;:.
1. �i�:•..-���' � � l:. 3.,
Irrigation PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT,
Non-Water Supply Well: C) fL ZC) ft. Gat d+o l IC) /3C4q-S
Monitoring QReoovery tL f4 (1
Infection Well; [t n
Aquifer Recharge ®Groundwater Remedlation •
'f9,1 �T�A/,rRAt Dili>PA'.01(Ifk�111�fh�1� F;rr� ' <,;:;<:�<:;.;<:;; =: r,
Aquifer Storage and Recovery OSalinity Barrier PROM TO MATEI�,4 EMPLACEMENT METHOD
Aquifer Test ,.,-A,.; 0StormwaterDrainage ft' ft.
Experimental Technology ‘
p 5:,�• OSubsldenoo Control [L ft,
Geothermal(Closed Loop) QTracer lr;Xb��T� KI� bi)b'(itptfxffpdi118' illihei4itflFi�ap�eft)i. z.'r:; :;rC
Geothermal(Heating/Cooling Return) Other(explain under I21 Remarks) PROM To DESCRIPTION(color,herdnetr,zolUroek type,stein size,NO
'6' QQ I 0 rt. go ft. C I(.,
4.Date Well(s)Corh leted; -✓-2 1 Well IDtI • 2( I fL ('i'5 ft. Gr Q I f-1
5a,Well Location; ft, ft, i\` .,r L V F^�`
it, ft.
0gkWood lib Mt S Ill 1 2 2024
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Facility/Owner Name Feoliity 1DN(If applicable) ft. ft, .
1Oty I it. it. s.
an Or , Lawyidal j./G :r,;c; kd:C,�
Physical Address,City,and Zip ft. ft, E'ftCuICv
�'.(eye)cond ;a a a,>..o:,s.%:'-,u;i,;.. ,;,;:?:yr,..::::.r::.=. ,. .. t:. .,.
County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degreesi.; '
(if well field,one 1st/long Is sufficient) • 22,Certifcationt
35,u2613 N —$1.c)36So w ( /(� ' f
6.Is(are)the well(s)aPermanent dr f Temporary Signature WJ e Contrel D to
By signing this form,I hereby cart(!'that the well(s)was(were)constructed in accordance
7,Is this a repair to on existing well: ©i Ysn or allo ' with/SA NCAC 02C.0100 or ISA NCAC 02C,0200 Well Construction Standards and that a
1flids is a repair,JNl out known well construction ht/brmallon and explain the nature ojute copy of this record has been provided to the well owner.
repair under b21 refearkssecllotror on the back of thisJo,ut' 23.Site diagram or additional well details: •
8,For Geoprobe/DPT or Closed=Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Uidicate TOTAL NUMBER of wells construction dotails. You may also attach additional pages If necessary.
drilled: ,SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface; . l?5 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths(fd(Q•erent(example.3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 20 (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: 6 (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: ACrtrtleY 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
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13a,Yield(gpm) Method of test: rt,r 24c,For Water Sunoly & Inlectim Wells: In addition to sending the form to
r n the address(cs) above, also submit ono copy of this form within 30 days of
13b,Disinfection type:6410►"IY1 e, Amount: .C. ('.U es 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