GW1--05726_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well )Contractor Inform lion:
(/ 4 i
�� 4WATE1t✓LQI�TES� ii��fd;,kv .Gst'^4ie# lt'1 ,_its 4 ?f: 01
Well Contractor Name FROM TO DESCRIPTION
COA ft. 1
a.( ft. ft.
NC Well Contractor Certification
/Number ///`► j`,iup R( Gt(fdr mu7tl iii 111.4)TORIISIN'Elt(((f ")141316)' 'i? <4x-( 't'
7 //d4 4- 4, Z)n/ r J L ' FROM TO f� I DIAMETER in. THICKNESSJ� MATERIAL
Company
/ I " 4}L-G _ `a) P Vce
P ztW INN G.0 r D �; .H '�„;-r K•x_,- .
ry / r1t i1SIN 1 1 . . C4�tileO.theimal�a14i131onp)'kua ,i„r,> s:'
2.Well Construction Permit#t S0r '" /0.06 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. le. ,
I.
3.Well Use(check well use): '
ft. ft. I In.
OftigionBE E. ., '. ldkif:P.1 h"r,•;l d.'_#.8i.R a Ett1 •v i z' `'(
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. 'i,in,
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 4$.8010 1 gigi 4�.;, c kts, .W.i , r z,/gil G u iM Nj:. ?ela:;
` irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOITI
Non-Water Supply Well: �d ft. o_ ti' .j P Cyt /F, 14 biR QS_p6 GCjre
Monitoring ()Recovery ft. ft. \J
Injection Well: ft., ft.
Aquifer Recharge QGroundwater Remediation
M9 SAPIIR/3 "]<0VBI IACICrMi1Ap'UCable)f ft5KF.I`AMil:V l ..:i
' Aquifer Storage and Recovery , 0Salinity Barrier FROM. TO MATERIAL EMPLACEMENT METHOD
Aquifer Test - '` ' Stormwater Drainage., ft, ft. I;
Experimental Technology \' '.x%Subsidence Control ft. ft.
Closed Loop) Tracer A2'U1:11RIII3LIIratig1'(8ftasl ad'dill$b"al'ilf 6?ifntceei(ar l se3Yii-k - ir' 5<s
FROM TO DESCRIPTION(color,hardness,solUreck type,grain she,etc.)
■Geothermal eatin:Coolin_Return) [Other(explain under#21 Remarks)
D ft. 44 ft. S lAK/ZVP f i (-1o(
4.Date Well(s)Completed: g A42-3 Well m# ft. )h fa A lv. i e,
5a.Well Location: ft. ft. L ' ' .
Facfii Owner Name Facility ID#(if applicable) ft. ft.
0 P Lies Dr, G✓'et n )i e ft. ft. ;; SEP .i 5 202.3
Physical Address,City,and Zip 1 ± 71 ft. ft. 1 y 1
// 1 �O J i is' g . yVl�Vi�R7 1111 -9. . f'W..0,t4,,ril
M
C 1_�b 1 Li'Tt13MARICS. ' ,...F_ a _ i a....-. J
County Parcel Identification No.(PIN) " -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' '
(if well field,one lat/long�i/s sufficient) �a /c 22.CerttifiDAA,L.:,,,
cation:
3 �7 3 dJ— N '-Y1, "! 6) f7'b W � i - 6'�J�
6.Is(are)the well(s) Permanent or Temporary
Signature of Certified Well Contracto , Date
By signing this form,I hereby certify that the wells)was(were)constructed to accordance
7.Is this a repair to an existing well: DYes or reNo ` —with"ISA NCAC 02C.0100 or ISA'NCAC'02Ci0200.'Well Construction Standards and that a -
If this is a repair,fill out known 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.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal 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: I' 'p I�� (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2®100) , construction to the following: '
• 10.Static water level below top of casing: /OL) (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
/ i
11.Borehole diameter: (o (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: V iD a Y' construction to the following: k
(i.e.auger,rotary,cable,direct push,etc.) {
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servicetenter,Raleigh,NC 27699-1636
t
13a.Yield(gpm) /0 Method of test: A-')Y' 24c.For Water Supply&Infection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: (!f it,le/.l'!Y; Amount: C l S completion of well construction to'the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Reaources • Revised 2-22 2016