GW1--04632_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,�1'ell Contractor Information:
G/a / n Pad t. _- - r s z_omm• + iu^ ' N ' 'y `V
..
WellCdaotorNamo FROM DLSCRIPTION
ft. ft,
tI636 A- rt,
NC Wall Connector Certlileatlon Number Pl a al1T E Cu'II d i;r)l�v�il�jf4;E�1�►N l d{i( ii'11'c;�d)&�%'::'::.-..
/ l FROM TO DIAMETER THICKNESS M ERIAL
CC1V11�S �V�ll col 11 �i1✓►i rJ j fL I I y . i,.?6 `50#3 2 1 V.-(�
Company Name �Y1A)ilol W7S41?ALQK2:IUa171 )f(4�:o71Ii y11117de213I6tlYi}'s1< ljs'.;('%..':'`;,+
yi W 23/ U1.-0 y�7 ,a (— I(MUTER THICKNESS MATERIAL
2.Well Construction Permit#1 �/) lac ft, ft, in.
List all applicable well construction permits n.e.UIC,County,Stale,Variance,etc.) — In
ft. ft,3.Well Use(check well use): rt. .i, r`'"cif;ri,_, ;?� �;,•'iEi'6s!;tT'w:;l:t':`his+;..y:.:.r%�=�: :'.:ii?t:::`•
Water Supply Well;
(t� DI Dt,33ER SLOT SIZE THICKNESS MATERIAL
�Muniol aUPublic rt.lUTIM ft. In,
•Agricultural P —
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. ft. - In, .
Supply ) : a�ia'', , , l,:lf&'> tl .' =I.'�iiti' (ti` ��'sf .;; :>`'•pf:,A f+��ia;'.
Irrigation
�Residontlai Water Su 1 Shared
PROM TO MATERIAL � EMP� CEMENLfETHOD&AMOUNT
,;onIWtlon L; f. 1,f 0 f4•(X� S
Non-Water Supply Well: �� c
Recovery ft, ft,
Monitoring � —
InJection Well: ft. It' I
Aquifer Recharge �j GroundwaterRemedletlon ZEROMMECOR`E)iiglealfge.i ';;KIP •{;';:;.9.•:4;,:)::..1;::• r:;::,fir.:'
SalimtY Barrier FRO TO MATERIAL EMPLACEMENT METHOD
Aquifer Storage and Recovery ft ft,
Test ,. • [ Stormwater Drainage
.Experimental Technology .,.,ti QSubsldenoe Control It. ft, � ••• � �'� '' :,
aa�--��lI,Tracer llgargl"t ;e.c0Orrii`�1i• lltif alTikiiiiliShi iiii43;.:,;,.,,ti;'::
Geothermal(Closed Loop) t ! FROM TO DESCRIPTION(color,hardnen,rolUrock type,groin sloe,re...)
Geothermal(Hcaling/Coolinj Return) Other(explain under#21 Remarks) C.' ft' L Jay
4.Date Well(s)Corlipleteds 0 2 7-i0 Well ID# I j e ft. 5(} rt. (]1^C41,1I •/f•
fL ft.0Sa.Well Location: • it. ft.
.tlr1'1 S 0 acborn k rt. ft. '1.1,1I� •a 9
Fealty/Owner Name Faoility IDN(it-applicable)
3 6 get r A S-ion e, Or., • •
ft, rt, —
WWI
lft. rt.
Address,City,and Zip '.,/'4J:':. 'v<?:fit"e;a•;"•'(::.r:''' ,.•.., ... .
County Parcel Identification No,(PIN) •.a
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi 22,Certification;
Orwell field,ono IeVlong Is aufilolont) ,)
35,L-J5 s'w 5 N 3i. gW'iCf y w � -l�-z�i
, SI na oftrertitlad ell Contra r Dale
6.Is(are)the weU(s) Permanent dr Temporary
S
By signing this form,l hereby oar*that the well(s)was(were)constructed In accordance
,sting...eu. r Yes or 00No ' with ISA NCAC 02C.0100 or 1SA NCAC 02C,0200 Well Construction Standards and That n
7
If is this a repair to snow:well , fbr copy'of This rrcord L:as tccn p:'ov!ded to the well owner.
If this Is a repair,Jillout known well co�strucllon h(/brmalfon and explain the nature of the
repah•under k21 reinarks-+action or on the back of this form. 23 Site diagram or additional well details:
•
You may use the back of ails page to provide additional well site details or well
8.For Geoprobe/DPT or -Loop•Gleothermal Wells having the same costatruotion details, You may also attach additional pages If necessary,
construction,only 1 OW-1 isa needed. Ihdloate TOTALNUMBBR of wells drilled: s►�$SUBMITTAL[NSTRUCZj
9.Total well depth below land sut•facer 0 1? (ft.) 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths(td( erent(example-3r@200'and MOO) construction to the following;
10.Static water level below top of casings J _____ (ft.) - Division of Water Resources,Information Processing Unit,
If water total Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
24b.For InlecNon Wells In addition to sanding the form to the address in 24a
t 1,Borehole diameters (In.) above, also submit one copy of this form within 30 days of completion of well
12.Well construction methods
U'74r it constru,otion to the following:
(I•o,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; rntectlon Wells: In addition to sending the form to
� r For Water 4ur,Dly deell_—
13a,Yield(gpm) !Method of test; 24c.the address(es) above, also submit one copy of this form within 30 days of
)-� Amount; C t✓ completion of wall constriction to the county health department of the county
136,Disinfection typal where constructed.
Revised 2.22.2016
North Caroline Department of Environmental Quality-Division of Water Resources
Form GWI