GW1--05706_Well Construction - GW1_20230905

, WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i.
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FROM TO DESCRIPTION
Well Contractor Name
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NC Wel Contractor Certification Number )51rO lVRIBASING`i;(fdii multi,oa idxweAi)iOR#I4MIllllflp Ha3i61e)j
J ) n_ FROM TO DIAMETER THICKNESS MATERIAL
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Company Na ,/ (j €16:AVN1rRYG' CrfUTt.!li[1BfPIGi(geothermilreTae3tliioA)u`•f v'� za}"'s-i
2.Well Construction Permit#: !/v �� O a-7� FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) ft. tt. In.
•3.Well Use(check well use): ft. ft. in
I`><I7tilditEE14CAMAi+ i 4 'I I c. ,4':,'t�¢v t. ! 0,:i0t0y0.war,:0
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
jGeothermal(Heating/Cooling Supply) II1Residential Water Supply(single) ft. ft. In.
industrial/Commercial Water Supply(shared) s!iSd1tUiP1t' nra ,, ;.., ( ? sh ;,m r"`. hmru,c:.3,.
I Irrigation FROM TO 11M^,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d R' AO - R' b e)L Yti 7 . 13 has.'- n p u. eJ
Monitoring Recovery ft. ft. `J I
Injection Well: ft. g.
Aquifer Recharge QGroundwater Remediation Y: ,
H1'9:iSANfl/OP.! ;PACK1(1fapAUcable)?.Z.K.. �. .;,'._:,-;SFr'�W4,`41 InCl gLi.,8/
Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test `.�Stormwater Drainage It• ft.
Experimental Technology A:•.1�Subsidence Control ft.
ft•
Geothermal(Closed Loop) Tracer Ia0�DRIIMITIG+1✓;OD;{attaeffdd nt[45i'si1 lfatiltii'eceeitiiii t ` 1 'r i R=�+:'•'tip.: :?V. .
3 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)• FROM To DESCRIPTION(color;harrddness,toll/rack type,grata rlu,etc.)
7 z) ft. .4,11 ft. Sa12116/a_df •
4.Date Well(s)Completed: "^'"�3 Well ID# 6j ft. / . ft. i✓et 1J l
5a:Well L cation: ft. ft.
Facility/O)wn/rName // f�Facili ID#(if applicable) SEPv -.'3-;
AZT RN) . v f 8P S i`G ft.ft• ft. 0 ti Zo23
Physical Addr s,City,and Zip ink.w r,ata:D
gb p.r r
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • ' I •
'(if well field,one bit/long is sufficient) 22.Certification:
3,St5"i6�I N — gl, 6 a w .� g-7-g-e 3
6.Is(are)the well(s)OPermanent or EpTemporary Signature o Certified Well Contractor Date
_. . , .--- - 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: DYes or )No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.5ite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop G,eo$hermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! 4� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2@100) construction to the following:
• 10.Static water level below top of casing: : 15— (ft.) Division of Water Resources,Information Processing Unit,
• Ifwater level is above casing,'use"+" 1617 Mail Service)Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in. 24b.For Infection Wells: In addition to sending the form to the address in 24a.
above,also submit one copy of,this form within 30 days of completion of well
12.Well construction method: Y1 d atsvy construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) g 0 Method of test: d.._l r 24c.For Water Sunnlv&Infection Wells: In addition to sending the form to
i , h the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type://l 0 V I/A e- Amount: c completion of well construction)to the county health department of the county
5� where constructed. I
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22 2016