GW1--06271_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Inform on:
TON NO ,o r 4Lx+U1h'Ft�+ZEstU'd�itl "m`tia 3``, +e't% Sersat' § -tzt'd 3�Ti
• FROM TO DESCRIPTION
Well Contractor Name ft. a ft.
i P 10 Lir
g.211. A
NCvd Certification umber e. A
1t CA� ,110 ¶ • � FROM TO DIAMETER TRIMNESS MATERIAL
Company Name fy!'tN ! ! t•; $C j.- ' +p'�04.V , x` i rktg
2.Well Construction Permit*: 43° 4 P�sotx To arAM ,� MATERIAL
List all applicable well construction permits fie WC County,State,Fare e,etc,) ft. ft..
(In.
ftal
3.Well Use(cheek well use): t it. I
Water Wen: - a> C 6 I i: : ' • M- alfAt . .. a• x
FROM TO DIAMZTER 'SLOT SIZE r'! ICNEss MATERIAL
°Agricultural ❑e1uniclpal/Pablic ft. it. - ' in.'!
tlQeothermal(Heating/Cooling Supply) litResidential Water Supply(single) ft, It. in,
Dlindustrial/Commercial °Residential Water Supply(shared) g , » 1,-�_w».• s r: o,,,
i w a3 ' ill ' � �%t'` ` �3aa.. +"�a...:v bti
°Irrigation °Wells a 100,000 GPD PROM • TO _ MATE AAL P MPLACEM 5TMETHOD f AMOUNT
Non-Water Supply Well: 0 14 -o ft. 10eiltirit
d Of U!:
OMonitoring °Recmtery ft. ft.
Injection Well: ft.
°Aquifer Recharge °GroundwaterRemediation .a � i -,
°AgniSer Storage and Recovery ❑Salitvtty Barrier .s TO t ,• K.-'. mmmr neon
FROM TO MATEATAL LMP'IACEMENTMI OD
°Aquifer lost °StormwaterDrainage ft. ft. !
(JExperimental Technology °Subsidence Control ft. ft. I` '
(JOeothermal(Closed Loop) OTlacett <i.,a;as:1A* . 1'=1 ,--•4r,,.;t;''Y61ieia 5 at ` ",g• "_..
t7Geothenmai(Heating/Cooling Other(whim xplamn under#21 Remarks) m nom To u ms= Wan bard ne+rtsoiliresk tyati Iran .tat .
4.Data Well(s)Completes;a (° a`� Well ID# 10 it. MO ft. jl s e k
So.Well
Location: .�ye�' y /Mn�/h R.
S,6/r 6.r),e-t�ef .vr.I 1 U M. �-<,..,,,'i n ', a. ,',L.
F ty/OwnerName Facili ID (if applicable) ft' _ ft. T L�<<,^
53a1 11ea tt r rai It. I
Address,City,end Zip /j� �!� �( j�^ ft. ft. 1 r,`�.„A..:r� '-c r, ; e!
fC{i 3(00 V Y 6 D d► ?' 1 w'i" � � i ' '`'i " eRr�i 'e> ,-h'r'�, ,r`. 'GP` ' 'r'
County
• Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is Bogdan) 22.Certifies a on: I r y�
N W sie2,1 i
kalt i 4
0
1 -24
6.Is(are)the well(s): t't�a>7manetrt or l7Temaporary
of a,t!e d Well Corlfeaetor 1' Date
By atgningthisforat,Ihereby ad*that thewe/I(s)was(were)constructed&accordance with
7.Is this a repair to an existing well: °Yes or To 154 NCAC 02C.0100 or ISA MAC 03C.0200"We1J Construction Standards and that a copy
rats is a repair,fill out+Mown well construction b formattan and srplaln the nature of the eerie record has been provided to thew"onne
repair tinder#21 remarks section or on the back of thisfonn. e' " •
23.Site diagram or additional well detaus:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constr.:Am:info.
•construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I r d® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.) Submit this OW-1 within 30 days of well completion per the following:
For multiple wells list all depths(fdtoerent(exam*.3®200'and2@lop)
10.Static water level below toptensing: D-O or.) • For All Wells: Original farm!to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
(twoferievel IS above casing,use"tt+" ,.
11.Borehole diameter: ( 11"r (in.) 24b.For Inflection Wei Copy to DWR,Underground Injection ction Control(ICIC)
fax
iZ Well construction method: air
L 1 Program,1636 MSC,Raleigh,NC 27699/(1636
24c.For Water Supply and Open-Lo`ai Geothermal Return Wells:Copy to the
(La auger,rotary,cable,direct push,etc.) county envi:vnmental lamith department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 110,000 GPD;Copy to DWR,CCPCUA
r Method of test: IP r', Permit Program,1611 MSC,Raleigh,NC 699-1611
13a.Yield(gpm) 3©,� W
13b.Disinfection type: f 1.11 Amount: t 1 � t L
I