GW1--03841_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-1) • For Internal Use Only:
t, ell Contractor Information:
I1 a fa V) Pad .,,. r a;;,,, �:y.: :�,:.:: ;.
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h � l�}���l.�.t'I�U�.®�pt`�RIPTION f.•
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WeIlCott�reotorNeme Q «, ft.
NC Weil Contractor Certification Number ParsgairgirMINOME g.elaill#jto' aRR(ftg1'Il'cifili .: .'
n FROM TO DL�METER THICKNESS MATERIAL
I.GY�i ��dl t cnd �uwi� Co. I ft, Mill 6.125 in, SO121 PrG
Company Ntmo :Slips «7St11tgroFlNivaidigiMi6' 1 NIViTalrgil: V,,:;,`.°. ",••:
1 H 177 ' e u . '1 UNETER THICKNESS MATERIAL
2,Well Construction Permit#s ft, IL I"�
List all applicable well cousit ucelon permlls P.Uf ,Cowtty,State,Variance,etc.) In
ft. ft, _
3,Well Use(check well use); „,_in;i;C ;a,rr l;i�(I?4�a? H a;l '•`' :"'r;: r;.'5 ,�'.'':c r•>;;
6 L IEla nyfA t (:
Water Supply Well; • ;e„ rRi)♦ DIAM/1ER SLOT SIZE THICKNESS MATERIAL
BAgricultural DMunioipal/Publio
ft it In,
Geothermal(Heating/Cooling Supply) wResldontial Water Supply(single) rt. rt. —In,
DlndustriaUCommercial DReskdential Water Supply(shared) min.-,,,;,p,. :}iZj` R`+/.7144C(ilie i.-7.,a,;:;:,.:.;>.,••; , ...r
FROM TO MATERIAL EMPLACEMENT gMEETHOD&AMOUNT
1'",,on-Wtlon 0 ft, 0 ft. �►,„J. C. fr Lj3.
Non-Water Supply Well:
•Monitoring —
Injection Weill ft. ft,
Aquifer Recharge 0Groundwater Remediatlon "' r~ 't S'' 1,,.•
'9L�y (1�( ey(•ftiilIlekj)1�1�,r.t'k '! J•
EMPLACEMENT METHOD
Aquifer Storage and Recovery LSalinity Barrier o To MATERIAL
Aquifer Test [ Stormwater Drainage ft', R.a--��!tt,SubsidenceControl fL ft,
Experimental Technology f�r ; `.1::, ..
t-�tTracer , e ra5P1a ,a_,o s Ali,. tRIr TION(coior,hardne,soil oc r;v:,:
Geothermal(Closed Loop) i,,;r TO •
DESCRIPTION(color,hardness,soil/rock type,grain rizy Or.)
Geothermal(Heating/Cooling Return)2 mil
(explain under#21 Remarks) 0 ft. f 20 ft. lay
4.Date Well(s)Corh[ileted;V/9U/d24 Well 1D# /2J ft' Mill rant k..
Sa,Well Location; • ft, ft. •
Ot'J mi:6 vlxlc cz ft. ft. JUN S ZOZ�+
•
Facility/Owner Name Facility lD##(If
aapplicabblle) /
52 5 04ft/fly CI.. 136ta e 4
C y 7oi tl ft, ft, Irrtu;r w v£l 19'r arm:-1 t Wt
04
Ph sioeI Address,City,and Zip fkrilifLEt, ft. ,
County Parcel Identification NO,(PIN) `
5b,Latitude and longitude in degrees/minutes/seconds or decimal degreesi 22,Certification;
well field,one IhI/long Is suffiolont)
•35.55V67 N —V.,Z531"a W � � � l -� � �
' l ' Signature offled Well Conll�otor Dale
6,Is(are)the weU(s)�Permanent dr Temporary
By signing this fatal,e I hereby carl(/y that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or IJA tVCAC 02C,0100 Well Construction Standards and That n
7.Is this a repair to an existing wells (.�!jYea or �No _„,,r n-� ,. r�
Odds Is a repair, ill out known well copsfructlon ht/brmailon and explain the nature of the copy cf''":'"' "a="`"p o v f..ed rs the well owner.
repair under hi)rehiarks secilon or on the back of'hie fain 23,Site diagram or additional well details:
•
You may use the book of lhs page to provide additional waif site details or well
8,For Geoprobe/DPT or Closed-Loop•Geothermal Wells having the samealso attach additional pages If necessary,construction details. You me
construction,only 1 OW-1 is needed. Iltdloate TOTAL NUMBER of wells SUBMITTAL 1NSTRUCT;(g)ya
drilled:9,Total well depth below land aue:face; 2,0 S (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(0-ereitl(example-3©200'and 2@i00) construction to the following:
10,Static water level below top of casing: (O (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
((water level Is above casing,use"+"
11,Borehole diameter: 6 (In.) 24b.For Injection Wells: In addition to sending
the
form
of othe add ress
w4a
•n t� above, also submit one copy of this form in days
12,Well construction method: 1^b7L�'y
construction to the following;
(I.a,auger,rotary,cable,direct push,etc,) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
,/ r Water S�DDIv&Inlectlo�t In addition to sending the form to
]3a,Yield(gpm)_ �� Method of test: i`r r r 24c,Fsthe address(es) above, also submit one copy of this form within 30 days of
VII'(�I�t n _ Amounts completion of well construction to the county health department of the county
13b,Disinfection typ e C tl�s whore constructed,
Revised 2.22.2016
Form OW t North Carolina Department of Environmental Quality•Division of Water Resources