GW1--06340_Well Construction - GW1_20241022

I .
WELL CONSTRUCTION RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells ,
1.Well Contractor Inform on: • i
14 WATFtZONES: 1-.; 1
TO ry r o 'el
FROM TO DESCRIPTION
t v ft., . 00 t.1 y! P yl
Well eo�ae Name
ame
___9;Ail A '..1� f11LITERCASiM{for-mntti=cnsedwells).ORLINEItt5fal>Pea ) •
•
Certification Number F FROM 4 TO II DIAMETER THICKNESS MA
.� � " Igo
�J ft. 1 �,'� fa � E.�D� L�iW-"[/�i�'L ��
NC Well Contractor I `(��v 1114t AS�IIY .. . q\\„--// � q�r�� ����� Ukil � Let 1��xc G:���cosn�t�r�tuer�l +l�lwioi. <..1. .. .
Company Name FROM TO DIAMETER THICKNESS MATERIAL
(es1 v ft in.
2.Well Construction Permit li: C.CL f) 4011 (
List all applicable well permits(i.e.County.Star Variance,Infection.Rtc) ft. ft, in.
3.Well Use(checkwell use): 17'SCREEN
I a! FROM 1 TO DIAMETER 1 SL,OTSIZF 5 TRIMNESS 1 MATERIAL
:l Wilier Supply'Wan ft. 1 ft ' La
DAgrlcultual D unicipal/Public •
fr ft in
°Geothermal(Heating/Cooling Supply) f Residential Water Supply(single) 1
°Residential Water Supply(shared) 1S GROVT . r • EMPLACuii.inir OD&AMOONr
°IndusErial/Commercial FROM To ,r
Qlrrigation 9 ft. ,�r ..® fA bek ►h Ii-d1 j
rA 11 i w
Non-Water Supply Well: ft. H. 1 I �,e,�.
°Monitoring °Recovery ft. ft. I T
Injection Well: _ -
:•IlAquifer Kecnslve C ittrnunawater Kerner]union t 'Ay.until,ruttnvns.ran rrr aoimeamet
�� PROM i'TO I MATERIAL l EMPI.A cos
EWJ'METHOD {
uuo y Donis:.linil
❑.ittluiicr.`7ivragom,unccvvciy - -ft. �it.°Aquifer Test ❑StormwaterDrainage ft. I ft. I .
°Subsidence Control -'"- � .
QFxperimentalTechnology ::20B1tii:I;I1+IGLQG:{aaabliat11Gt1onnt"sHee�fnet�sary) ;:
❑Geothermal(Closed Loop) °Tracer FROM TO DESCpRIPTION(eator,hardness,soaUroerttype gram size,etc.)
❑()
°Geothermal(Heating/Cooling Return) titer(explain under 1/21 Remarks) 0 ft 5 f. eO•
4.Date Well(s) !Completed: !'�a Well Ilkt ` ft, ft.
Sa."ive?Ilocatioa: , ft. . It.
nick Mo7-110 ;. .
Facility/Owner Name Faciity.ID#(if applicable) ft: ft,
c6sI sfallt40 rot)1-e d 11 r 115(11 ft ft , OCT 2, i u14
�
Physical Address,City.and xLItEMARKS.: lr` j����!�,
���lNb h ly� ty.i5i:onts: -
County Parcel Identification No.(PIN) 1
i
f
• 5b.Latitude and Longitude in degrees/minutes/secands or decimal degrees: 22_certification:
(if wc bold,one twiongin sui ieic ut
N Dt
a-asgiA 1 a
Si f Certifi Well Contractor
6.Is(are)the well(s): Permanent or °Temporary ByW igning this form,1 hereby cent fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or EAo copy of this record has been provided to the well owner.
If this is a repair fill out known well construction Information and explain the nature of the Site diagram or additional well details:
repair under 021 remarks sectionoron the back ofthisform. 23__,t__ __ t_additi__! __ ,- -++:•=---+---�++�++� '- --'- --
• -,..-.ay',:., `+- uaa-v.•uu.yy,bv to y.v+.u..uuuu.u.u., n , ..r.u.,o.5 '01141
S.Number of wells constructed: - construction details. Yuu may itisu attach additional pages if necessary.
For Multiple injection or no,i-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form. '
9.Total well depth below laud surface: ? `" (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(ferent(example-3@200'and 2«100) construction to the following'
1Division of Water Resources,Information Processing Unit,
Ifwater0. e levelev water leveling. top of casing: (f t) 1617 Mail Service Center,Raleigh,NC 27699-1617
is above casing,use"+"e
11.Borehole diameter:.,_.. ..te r4 (in.) t 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
a-tl� 1T/!]r-p7, 24a above,.also submit a copy of this form within 30 days of completion of won
12.``rirfFwnuLL..N...0 1..r..a.s... ._ _- _..__,P
(i o.auger rotary,cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service-Center,Raleigh,NC 27699-1636
Method of Pest IQ 1 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 111 Also submit one copy of this foua within 30 days of completion of
f -
13b.Disinfection type: � Amount � � well construction to the county health department of the county where
constructed. f
Form OW-i
North CaroDepartment Carolina of Environment aeti Natural Resources—Division or Water Resources -Revised August g6T3