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Home My WebLink AboutGW1--06061_Well Construction - GW1_20230921 : �:llilul?�+t<wt WELL CONSTRUCTION RECORD(GW 1) . For Internal Use Only: - • 1.Well Contractor Informs on: r i A j 4(Rgg:�r'�'y.�5,+��y��i� �}yy�iz�ilijC�"ss s'•�1 A��:�e y'};, 1:�2 r.<.; .,,�o.p,4,10,s. ,... i .,...4,,, '�i'�/,�' by Y 'l, '4Yf��Fviit+.1�:W id'i3 1'-f�l-lr'.:!{tf1;.. i1i2��:.. :»t;iifi-Y..:A.Yi.1v.,i'ii�`•::rvt:.i.;,,:,.,.,, Well ntractorName ! FROM TO DESCRIPTION . ft. ft: I I a2 i 3!A A ft. It. . • NC Wpil Contactor Certiftcati n Number • //� �j ;`1l40ttTEle �' NGf((oViii s Afliiiivelli5.:XPLI IMOlfiki. glib lou 1_' ..'� 6 J. )) 1 ��) (rA ,AG . FROM TO DIAMETER TrCKNPSs MATERIAL ([[///vvV�f/ ,J / . l ft' 6 .ft. 4,/ tn. 6PR- _1 Pk., • Company Nam �A/� 3 ii316F1M+81ti 'A`Sll!1ft91b1t�ACJBDi!TGt(sill(ti I illoltJriltl$OP)ii< '`sk:...,,,is'.•`r. -'= ,, 2.Well Construction Permit#: U FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in. 3.Well Use(check well use): •J yB' 1 fry.�� ID. Water Supply Well: tr14t)gt7E E.is�:: N.4.'f a trt. ' 0-1.4. k";vx`#'.r Ys-"'#ii :.:•..,iffi/iW -;NI �`r"f.� PP y • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural DMunicipai/Public ft. . ft. : - in. Geothermal(Heating/Cooling Supply) IBResidentlal Water Supply(single) ft. g, !, . in. InduatriaUCommercial E3Reakientiat Water Supply(shared) �yp/�'� Il:"•,nt:c ,: �,•;�,;• rr.1�z� :ter i lri_ t�.v; iiii 3 uF, �Wf . ib1$StG1l;q�PR{S.•,,.i:�jflJ -:1+,:lit; ��'f.e e i.. �r�:.1�•rY,7�r••.i�(ti�.-.t-•'k�"+1��`'7v=Y��'„ Irrigation FROM TO MATERIAL-- EMPLACEMENT METHOD&AM°�UNT Non-Water Supply Well: 5 ft'' Ao �' Ii e)Ue)1i to I•6-.lad S-p oa(r�d Monitoring 'ORecovery • �• f. . • Injection Well: • ft. ft. Aquifer Recharge OGroundwater Remediation ir)19:?R'1. .%dftWatlintO11A`llPllfYlili)'ts, tl.",`•.c:�'.�^iW-:;;.WAWA:W::1..V.1.;.iA Aquifer Storage and Recovery ' Salinity Barrier - . FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test . •, •,•`. O Stonnwater Drainage ft. ft. • Experimental Technology •• ••,;�' OSubsidence Control ft. ft. Geothermal(Closed Loop) - 7. OTracer O�R11R{'tNGIO:( (d(tabjtfedi11ii811 nli tii+'lf�treWit )h: Y? ':"rh;'}tt'•%Yg.='4 Al r FROM TO DESCRIPTION(color,hardness solUreek type,grain eke,etc.) • Geothermal(Heating/Cooling Return) riOther(explain under#21 Remarks) ft. f<' r /� 2 a 6 6 of D 9 rave h1lx 4.Date Well(s)Completed:-"/'�, J/ Well ID# �,7 f i• 7 5 f t' ' ) era./fe. Ss.Well Location: . ft. ft. • I-f;a.-1 5. �J v kris I)n: -- ft. ,, ft. t= � �1..=T`s.` ~ 'F Facility/OwaerName 19 Facility ID#(if applicable) h' ft. ' 573��r� (°is Pot,At: i eIJier rt. ft. SEP 2 i 2023 . . Physical Address,City,and Zip 1-0/—$/J J ft. ft. I' I for- 2 izm P t^,c.5.-.+.'.9 Una i t� f?„,„ ,: ray ,,,,• , Al.4 �al�w i`Z1t1tBiNGtl(CR:y>-;;:.} :„.„,.,:.;,..„,„„,, County Parcel Identification No.(PIN) - 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• . (if well field,one Iet/long is sufficient) �y �+ /� 22.Certifcat_lon,: • 5� � N `'25 -0 d� W �fvimO l�—z5 6.Is(are)the well(s)i§Permanent 'or'OTemporary Signature of Certified Well Contraoto ate By signing this form,I hereby cert(/y that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: OYes or II1No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,Jill out known well construction li ormation 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: z SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: Q (tL) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple.wells list all depths(fd(,fferent(example-300'and 2®100' construction to the following: I. 30.Static water level below top of casing: • 60 (ft.) Division of Water Resources,Information Processing Unit, - If water level is above casing,use"+" 1617 Mail Servi(ce,Center,Raleigh,NC 27699-1617 11.Borehole diam / eter: ( (in.) 24b.For Inieetion Wells: In additlon.to sending the form to the address in 24a 12.Well construction method: V,a-rQ-r y above,also-submit one copy of!this form within 30 days of completion of well. construction to the following: - (i.e.auger,rotary,cable,direct push,,etc.) 1 •- . 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) 9 40 Method of test: .a—/ i'' 24c.For Water Supply&Inlection Wells: In addition to sending the form to , the address(es) above, also submit one copy of this form-within 30 days of 13b.Disinfection type: (JI )DY► h Q. Amount: d2 . 1 completion of well constructionI to the county health department of the county where constructed. Form OW-I North Carolina Department of Environmental Quality-DivisIon of Water Resources Revised 2-22-2016