GW1--06618_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For Internal Use ONLY:
1.Well Contractor '. Information:� 1
' In -f K i '-� _`V-k 1 I 5 114.:WATER ZONES. '.I.
PROM TO DESCRIPTION
Well Contractor Name ft. /40 ft. f /gr /
6.e3 - ik /4o ft. y,0 ft. 1/ a l3rFi.,
LNC Well Cantmcto eniGcat/i'o�n NC�mher .:1S:OUTERDASII/NGv' ailatilH cescil Wells)ORMINER(it`np lienlile)•::7'
6C.t.t.5t �( }•� G I�EL/ 1 f FROM I � / R THILRWESS 1 MATERIAL
_" -` i.+�.+/.... �I (�1 tJ� ft. ft. 1 / In. 11.Z I
Company Namei:16:INNER.CASING'OR'TUBrNG'(pooaieiniol�closc'd-too
pop4,s FROM TO DIAMETER THICKNESS, a MATERIAL
2.Well Construction Permit#: ft ft. In.
List all applicable well construction permits(i.e.Como;State,Variance,etc.)
3.Well Use(check well use): ft. ft. S In..
:17:SCREEtV••:•i•:•Ti ,;..::.. .:.:. n y<.
Water Supply Well: :;.._::;:':;;5{::...::::....•::::
pp y FROM TO 1711.'
R, SLOT SIZE THICKNESS MATERIAL .,
❑Agricultural ❑Mun/i9ipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) ti7 sidentia(Water Supply(single) ft. ft. n
❑Industrial/Commercial ❑Residential Water Supply(shared) 1'18r GROUT: : ,:;•., .'.:;;;.:_;,:c,•.':: :-:•..
❑Irrigali011 FROM TO''// hATERIAL ? &rcd
• Nan-Water Supply Well: to rt. �1t ft. 4fD, n/- _❑Monitoring ❑Recovery ft. ft. r!\J'/ �+ js
Injection Well: ft. •ft.
❑Aquifer Recharge ❑Groundwater Remediation :19:SANDIGRAVEL`I'ACIG(it:otipiienhic);::: ;_:;i••,;_.:;.,a '•:••.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S ft. ft.
tomwater Drainage
❑Experimental Technology ❑Subsidence Control ft fr.
I
❑Geothermal(Closed Loop) OTracer 20.DRII,LIlVGa OG(6ftucli naditi nal'sliceis if•o'eeessuty)`'?tt::',:.•. :• •, ;.;,; ;:
❑Geothermal(Heating/Cooling Return) ❑Outer(explain under#21 Remarks) FROM TO DESCRIPTION(toter,hardness,soli/reek type,grain size,Inc.)
O ft. AO ft.
4.Date Well(s)Completed: lc. - I -Z.O 2-_,.. p2 0 ft. ! Q ft, p_� .
5.Well Location:Q , Jo ft. _cot ft. ,5•��LR�?Le_ oe.K
\I R. Cole�'1ii�N ft vr•a ft (2 cjt5 �'"F�
Facility/Owner Nome �a ft, p9 Ob ft `D/e',� d y
/H^� Facilityy/r ID#(if applicable)
i 6 /G.xle
/°575)t V 1l ve►td. /t,6 I eAs NV ft. ft.
Physical Address,City,and Zip >� ft. • ft „ ,v i 1 r `f
f' tz1.`•327 htAltI(S, .: v
e-14 Ca
i O C T 1 I 2023 •
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lnt/long Is sufficient) 22.Certification: lit'`""`"" -`3..,...,....-
''3 Lit•r;i
��� N W ` - Cli7, -xo-zoz3
6.Is(are)the walks): y ermaneut or ❑Temporary intone Of Certified Welt Contractor Date
By signing this form,I hereby certl that t(ie well(s)was(were)cour:n,rted in accordance
7.Is this a repair to an existing well: ❑yam or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
•
If this Is a repair,fill out known well conslrnctlon Information and explain the nature of the copy of this record Gas been provided to the well owner.
repair under#21 remarks section or on the back oflblsford» 23.Site diagram or additional well details:
8.Number oflvells constructed: � 6= You may use the back of this page to.provide additional well site details or well
For,multiple Injection or non..watersupp/y wells ONLY Wits the same construction,you can construction details. You may also attach additional pages if necessary•
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 4 6
For multiple wells list all depths idierent(example-3©200'and 2 100 For 24a. For All Wells: Submit this form within 30 days of completion of well
© 9 construction to the following: i
10.Static water level below top of casing: 46 1. (ft.) Division of Water Quality,Information Processing Unit,
ljtt ores!evens 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
12.Well construction method: e7TC�.1I above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center Raleigh,NC 27699-1636 •
13a.Yield(gpm �� �r 24c.For Water Supply Geothermal Wells: In addition to sending the form to
Method of test:
���ey�. y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: }� Amounl4%� 707 Z completion of well construction to the county health department of the county
where constructed,
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jtuu.2013
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