GW1--06614_Well Construction - GW1_20231017

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: v
• 1.Well Contractor Information: f •
if..,r reit /p ci!✓ - - sea A;fi mats l- ' �t #71t-'ino,+.l��tii:r'#Yte l{;i! tymmtv'. 'wigi
FROM TO t !DESCRIPTION
Well Contreo//torName //��
ft. MIii✓-1k5A-
ft. ft.
• NCW JlCo'nrectorCediflcaatio)aNumbor '/ i'`rlflRIOMB lb(4�f((o51f t01.if•ic'4i'W!bilii)l }tumor NiilE(�)p°'.ao.: :::' ‘
7_,Le / . tr V e-I I lr Pl_{� 6. ��G FROM TO . DIAMETER TffiC MATERIAL
.i / liw4s It' ,/a.s in. SDR1t PVe-
Company Name/ .it+lbilT+li011 Ot' QR l)ll• '(@ lre'i'idt lliifbi 1l) ftR lsh i yr':l;��a'tt;si g
2.Well Construction Permit#: /r/urKP_-a FROM TO ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,.Variance,etc.) H. . ft. in,
3.Well Use(check well use): C�WyN�Y y t } h �ft� 1 Z 4,�� �I i t r /
'2 brill i7.lR/19 p�:ik)lyiiC�ft1Yo.Ats�..:flHYikr.7+t.¢}`iAS:,FS PARR?SMP.atialfiV.01})itMf;�{1 ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Publio ft. ft. 1. In.
Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single) ft. it. i in.
Industrial/Commercial (shared)
DRasidentlal Water supplyiagkKfi'cWi'{aRA4�c�a:�I��NS '°its"KWAVS W'ti3/e>rtagx;�ta.MOV•4l
Irrigation FROM TO MATERIAL_1_ ' .EMPLACEMENT METHOD&AMOVNT
Non-Water Supply Well: (2 fa ,f..0 k' bC'K 12.ntte I 4 h,c,j 5 - ,OQ 1A
Monitoring QRecovery - rt. H.
Injection Well: -• fp - ft. -
Aquifer Recharge 0Ciroundwater Ramediation 4.•,t.., �,);,;,�t'�t �,. ,;.�, ' Ir; ,2
1 9,118la1!1D.'lt3t 4fifll. f (tiluYiiilallftt)if�;x•N.I IV .A"`;/..,,Y,, i t,430, ,;<�i�w'• ;s':;':: >,.
Aquifer Storage and Recovery ' ' 0Salinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \ ti• OStormwater Drainage • ft, ft, •
Experimental Technology .'N''. ;''\' QSubsidence Control - ft. ft. '
Geothermal(Closed Loop)"s• . ' • QTracer V'r 6ii' RIM/.iMB0:(t(a"tta`bNiaildtilliffdl?1Ee`'tilfill/irta iiiil'1:4h'lX1tb.?,-Y`;;tr !•is: ,;,;K
FROM TO DESCRIPTION toter,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling
Return) nOther(explain under#21 Remarks) 0 ft. ,9 n. I, . Q y. ) 1/ 'r 7. G'/g y
4,Date Well(s)Completed: P Ott")��� Well ID# �f 6 ft' tp D5 ft' 1 q Y�AGN4� e,
5a.Well Location: . ff ft. ft. �J �;y k f, ,;S r,.,n
Za- h11s le- ft. ft. l' e,.,-fi-.N ii ls' .:a`;i.jl
Faclllty/0w arNemo n �� t Facility ID#(If applicable) ft. ft. ; OCT 1 7 2023
�f o rein Ln_, ft, ft. r.
ft, ft, i:f. _,;;,;. fit
PhysicalCi and Zi ��``",.'"`-lr�
y Address, 1 �.�(��y � ,.1., J•P' f'.(.-,.• .^.tyl.: -4.!}4�1.1
/1 ,k1 irf a+ o . ' r ;-• i•:f:,... t 14::;:4.3„ �:w5+''„ ,,,ri':2'.:,�..:
/� J i; ,'%:fi54�Z "6Z.a,-. ..,tiv, '!:=.i`ivi.-.......(.:4'.... .. ,:::...
County�'Jl lN/ Parcel Identification No.(PIN)_ -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• ' `
Orwell field,one lat/Ioag Is sufficient) ` 22.Certification: •
3JJJ, /-2,1 N �7 D I, 76Z(o�" W .!/,G /,-.4,-z3
Sigmture•ofCertified Well Con rotor Date
6.Is(are)the well(s)�Permanent ` o� QTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this if repair to an existing-well: ..QYes -or liNo. with 1SANCAC 02C.0100 or ISA NCAC 02C.0200 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 baok 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: pUBM1TTAL INSTRUCTIONS
9,Total well depth below land surface: 6 (ih) 24a, For All WeUa: Submit this form within 30 days of completion of well
For multiple.wells list all depths if different(example-5f 20 and nd 2(01005 construction to the following:
i
10.Static water level below top of casing:' 4� (ft.) Division of Water Resources,Information Processing Unit,
(/'water level is above casing,use"+" 1617 Mail Seri ice Center,Raleigh,NC 27699-1617
11.Borehole diameltir: (in.) 24b.For Infection Wells: In addition to sending the form to-the address in 24e
above,also submit one copy'`of this form within 30 days of completion of well
12.Well construction method: • r D I (/ construction to the following:!
(i.e.auger,rotary,cable,direct push,eta.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test: IA 24c.For Water Suauly&Infection Wells: In addition to sending the form tc
! the address(es) above, also Submit one copy of this form within 30 days of
t completion of well construction to the county health department of the county
13b.Disinfection type: G�IO{^/h Amount: C.u where construoted.
Form OW-I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201(
,