GW1--06322_Well Construction - GW1_20241022

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1.Well Contractor Information:
:,. 7 oan h f pb 1 e 14i WATER•ZOP}F,,R: • .
FROM TO1[� DESCRIP ION.-
ts''ell�gl e ft. 0J � 1
j .1 .I, 9 f wl
I.
NC Well Contractor Certifies'on et IL.flIfiERR C%NR�1G'(foi+miilil=taxed wdh)flit f!NRRtif o:•.
Cl r4 Po'i1 l I �, Film _ To 'DLAmETER
C\yt ,yy TIFBer sS AfATERlAF
_. 'rs reatrtu reC't[S euvr mine- 'r bn�,....t a.....io.;, .- - .�.
2.Well Construction Permit#: GUI 10 I 0-I 1 w a'b a3 F oiif •- TO DLIMETElF THICKNESS TERM
2.
List all applicable Well permits(4e.Cft. �' in.
aunty, Variance,Injection,etc)
3.Well Use(checkwelluse): ti• '
Water Supply Well: l3 f7 St FtEFTsI .
FROM TO DIAAMEPLTi SLOT SIZE TRIMNESS MATERIAL.
•
❑Agricultural , unicipal/Publlc # al
in
rg..c:l.; ,A.:c-.,tia::a_.S.__,.;_:__,_. ft.
1_klincirialfera•. t¢` `�r^a�U .
•••.-nC�Cial i�lteslelential ratei Supply .r 01, a .. • .. ; .
iy (7I,i,}(3lliirrXt) &Rf11r I�Tn 1 nre'ttnre7 I crtor.nanacnrrnrt=runn r.•nrnrnrn
CIltrigationlc> _ i"Y
Non-Water Supply Well:
° k ZA ft berth D ill'i f 4 v
❑Monitoring ORecovery ft. ft.
' � rJ rr} it
Infection Welt: , ft j 1 r't ,
EIA uifer Recharge I`'
q . g ❑Groundwater Remediation .19;S;':,PiDIGRAVELPACLf(1fappl , ) • ,
OAquifer Storage and Recovery !]Salinity Barrierft. ft. i i,
•
t!Taos! TO MATERIAL ,uniFtr c r MErpon -
°Aquifer Test OStormwater Drainage
1 DE ,w:erial Technology i ni;sideriie Coal ,l a 1 l (
uuwu,cwtartarwcu�ti,irl ulracCr I 20..BY(ILLIfIf l:t)OtatratgaddlitntinlcheeeiifneeQ;arinria..
FROM • TO DESCRII 7ION calor hardy aallireek it._. etc."
OGeothermal(Beating/Cooling Return) ❑Other(explain under i/21 Remarks) 1 WWI ( � b st
4.Date Well(s)Completed:5°I3-c I Well ID# • � /� ro . 1 bG _
5a.We117,ocatien:
O
Rt.� ,raS well > 3 ..
. C2ciiity.0..,.. iiiii A.. .. a )•,.., ,
52./7 ae-Pt teed elr,, R4 istlil 117(064 tt.,:.1• ft l
Physical A ens,City,and Zip I it ' OCT 2 J LUt r _
Wa g° b1$ 1�0 Ii 3 a9 Z;:REMARKS
County Parcel Identification No.(PIN) G'. S; '�>y.; v
Sli.Latitude and Longitude in degreeslminutesAcconds or decimal degrees:
(ieelffield,one lar/long is sufficient) 22.Certification: I
(( iv.' IV . i)64 4 4 1— Ncol L6 - 13 -24
�J// Signe -e ofCertifcd Ci cli..oubw.tur
V.ca'iut cl we\cuts): AtrCr►uauedi or Li i corporal 'i7ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: dXea or "Nowith ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
tIis is a copy of this record has been provided lathe well owner.
If repair,,ftll out known well construction information and explain the nature of the
repair under h21 remarks section or on the hack of thisArm. 23.Site diagram or additional well detail&
You may use the back of this page.to provide additional well site details or well
&Number of wells constructed: t construction details. You may also attach additional pages if necessary.
Formtdtiple imecnon or non-water supply wells ONLY with the same canstractlo,you can
submit ouefartn. SUBMITTAL.INSTUCTIONS
RloMil well depth below taus surface. I `
0• ...- .._.._ _ar --.,._ .... ., ..;:,.... E this Ff .: �ft. ?,•> �:.r :1l Wells: met f s form �,,:rhir..,u t� .,,�
_.__ ��s: Submit � „ o_completion #:av wort day` mp a -
•
10.Stade water level below top of casing: S ( )fr Division of Water Resources,Information ProcessingUnit,
Ifwater level Is above casing.use"+� ? 7 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: 6) On,) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
1Z:Well.construction method: (Ai(' 6�Q r'� 244aaboveb also submit a copy of this form within 30 days of completion of well
(i.e.auger_rotary,cable,direct push,etc.) eanstrlletion t0 the fallowing
?�I WATER ;�7 - "."--71 Division of Water Resources,'Undei ronad T j c Control n----
FOR T.R a `,}} In 27ail 3 A r V�r a1U,
j L VL 1: LO
(-I :y Y5�5 ' it2 ce„3ee Ces3ter,' a h,A.0 275';'-ifi13a.Yield(gpm) If0 Method of test: ®w !Q .1.4c.a or"Water Sunnily�c infection W*In
11,w� Also submit one copy of this form within 39 days of completion of
13b.Disinfection type; V\ Amount: ( Z well construction to the county health department of the county where
constructed.
Form-OW-1 North Carolina Department of Environment and Natural Resources..Division of Watei7tesourees
Revised AugusC2tlI3