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Home My WebLink AboutGW1--06290_Well Construction - GW1_20230926 I. • WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: i 1.Well Contractor Info matron: d cV��'��11��/// - trt �f1y,�hr��rie,� ty yl;sii�l'v..�Y a't'_y u�.2 +� �'�.a h�: ity Y+:,:,i`.�':�/•'r.;:.:l.c-�:;r�•i n6Lv., Y�"`� r� �{ifi5„�vgM'+ }PKit�`� t4.aG�71?=/47�:fcv-i�. fi ;.t'.l5" tt::l.Y::.i..�.4, .r ii;n•..:. Well Contractor Name I FROM TO DESCRIPTION .A/3 A ft. ft. ft. C ft. • NC W ,Conhactor Certification Number //// y11 R j}�$l[i((y((foc)5:it .p livellh)A illI[ 1RI(iftd 1lZriflirlf ut.i, } ':. ':::,9 S��(� ,)-Pano / -t T�C, FROM TO /� k. DIAMETER`� , in. � THICKNESS MA2ERIALC • Company Name JJ d A /`i 4 'v;lG INNEli 'tlsIN'e 015)..I(!eiabiall(ei t1l7i4p)'tlr= ��itRAixFSs '.�:K��:..07a 2.Well Construction Permit#: 1.7/ ` v FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(le.UIC,County,State,:Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. 10.• f t h. ;! r 1 1 tir 1 P,tf'tj.tlila.`..io�'ra+�:d Water Supply Well: txxo l�O,l� (br 3sl.r "t% l ;i .,_` f�.t: .t�5.._T..a., DIAMETER SLOT SIZE THICKNESS MATERIAL ['Agricultural OMunicipal/Public ft. ft. I In. ['Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. g, i hi. ' Industrial/Commercial Residential Water Supply(shared) q 5lrr A4 +kr hsr) f,fa{ ;:,i � :i r;'i^tY;�?a.k)T"'f r`r',> �;r` 4:.E l w4 r={. I��OMt��V 41�5 ...: �i,i.:J fdjl..}� {Y�` , Irrigation FROM (ThO MATERIAL EMPLACEMENT dMETHOD&AMO Non-Water Supply Well: • d ft' U f t' be it art 7 e. /6"hags - too gre._ ❑Monitoring [Recovery ft. K' • " Injection Well: [t. ft. gAuifer Recharge OGroundwater Remediation i14:ISAt4b%d ` PAC1l4�(t#tlq�►plt�alilm)ia;=:;,'! i.l<��s<sY�rdv!ri=xr % :4,;i}?: Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD 0Aquifer Teat • `•. ' OStormwator Drainage ft,. H. . ['Experimental Technology ,-��'\' 0 Subsidence Control ft. ft. • ['Geothermal(Closed Loop) .•' • ['Tracer taOliblsklll4 UC Zatiabltld'fddll 16t5tiAli11' (i ifii(e Viiiiy)itiiII i::.-°r-IR `; W4 0Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO' DESCRIPTION(enter,bardeeu,toll/reek type.grain dre etc.) ... 0 " 5-9 ". d'1'!nt G.Qy 4.Date Well(s)Completed: —� Well ID# 665 fA N 4I(('1^Gt�'(1 t[°r ft. ft. Cf Sa.Well Location: • 171 -r^ Facility/Owner Name t Facility lD#(if applicable) ft. ft. "'m""'-s 1-- �% i._ a„i" Zo6oZ. Pikirt Pelel Or.. Bessemer (t`f . ft. ft. SEP ? .( 71123 Physical Address,City,and Zip / f it. y/i r c , ;ti '�5 ' ... tK...Ntr(xT,•.�t•?cjii;- .,"i•'?',X<iy vri: ?l.,- ((/,.JJ= 1/fib yam i m'l/(. 1�: �l.;tY:' t • ,,,,.,ti::1;: t. :z,:,-.:•!:: EpV��51{R iVf/tt{R�P�'t:-.•Sj�... County Parcel Identification No.(PIN) _ • I 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees[• • • • (if well Sold,one let/long is sufficient) 22.Certification: 5_ .g3o I to7 N. —1/- e8 9/6g W 9-.2s23 `, • Signature of Certified Well Contraotoi Date 6.Is(are)the well(s)16Permanent or ['Temporary . By signing this form,I hereby certify that the wells)was(were)constructed hi accordance 7.16 this a repair to an existing well: DYes or No • wIth 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a '. I this is a main/Ill out known well construction Information and explain the nature of the copy of thls record has been provided to the well owner. repair under#21 remarks section or on the back oft*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: : 'e (iL) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple.wells list all depths((different(example-3@200'and 2(01005 construction to the following: j 10.Static water level below top of casing: • ('P 0 (ft.) Division of Water Resources,Information Processing Unit, If water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 • •11.Borehole diameter: 6 (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: rO ry construction to the following: I (i.e.auger,rotary,cable,direct push,eto.) / Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servic&Center,Raleigh,NC 27699-1636 t 13a.Yield(gpm) Method of test: A 1r 24c.For Water Sunnlv&Infection Wells: In addition to sending the form to 11 t the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: C k/o r11i e. Amount: C�- ..6 completion of well construction to the county health department of the county where constructed. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016 Form OW-1 1 ' •