GW1--06620_Well Construction - GW1_20231017

i
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
t t
•44 WATLIR'ZONFS,::;•.._-:',,•<',,':C::::r.-.;.:....;.'-...:.'• .•. ....,,_........
FROM TO DESCRIPTION
Well.Contractor Name 1 ap ft' I U 0 ft. i 6
IIi -� t I ` •--,--.,o / •
L�C.Lr S ( PWvt.� tY l i e LL 1 )6 I l(&3 ft. ft.
NC Well Contractor Certification Number \J AS:OUTEIVCASING'(for rirulti•cascil waUs).OR7JINER(if aji lieabIer.-•'-:.';:.{;•,�,r.
Q FROM TO DIAMETER THICKNESS IV ATERIAL
Ci i tt. 11oa.i'r I b ibl:. in. '6DR at PVC COmpmry Name I '•16i+INNER•CASING,0-wrUDrwakeotlicriiiiva scd-loopT:-:,::.. -':•. ,
LIFROM -TO DIAMETER THICKNESS MATERIAL.
2.WellConstructionPermittI: ft. fr. in.
List all applicable well construction permits(Le,Coen%State,Variance,etc)
ft. it. i in.
3.Well Use(check well use):
':17:SCREEN: •.r ;.:"!'::, ......r, F. '";a v::..
Water Supply Well: FROM TO „ DIAMETER SLOT SIZE THICKNESS MATERIAL'
❑Agricultural ❑Mui cipal/Public ft. ft in. =
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) ••18..GROIIT.�:::. st:'.4. a:'-`:;•',i ";• - ;.:•_.'_.::. : :: ..,.., ...
❑Irrigation FROM TO afATEtUAL EMPLACEAtENTbfETF10D&AMOUNT
Non-Water 0 ft. I..:O ft. g�!}on',4e. Povre,� ; `1 I-3(.,,•�5
❑Monitoring ❑Recovery tr. ft. C..hi q 4
Injection Well: ft. ft. i
❑Aquifer Recharge ❑GroundwaterReneediation :.19:SAND/GRAVEL;TACINificinlienble)`: .c:'.:;;'•:.''. :.:;:::'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMI'LACEMENTMETI]OU
❑Aquifer Test ft.
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. rr.
❑Geothermal(Closed Loop) ❑Tracer 20.'DRIDLi1VGI OG•(hftacliitOdiedanlahcets irnee6ssary)`-•'::::.:_,s,t.-..,.. :,,;
❑Geothermal(Heating/Cooling Return) ❑Outer(explain under1l21 Remarks) FROM To DESCRIPTION(color,hardness,sotUroektype.Rain sire,etc.)
O ft* $p R. So` '
4.Date Well(s)Completed: CX ✓at) -aO-3 80 ft. 10:. it. SO' I 1 d I2,0 .K
ft. loa- fr, Gas�Gi
5 ell Location:
pCIL;la t V er to a, ft.. I bow
ft. S O 1 1 d
Facility/Owner Mune ft. ft.
__r Facility ID#(if applicable)
y ` __
/ CS-fro Cr)bie6rY �56a.1Ac�(CY(V, ft. ft. ' , ,r �,,n
��
Physical Address,City,and Zip (� ft, ft.
121 '��....F
cS C'_t� :It>AIABltS -... :e`I,::4 t, .::....., :•4n:4:�} .:..1„,'.,•:r :`•;:.'::>..
LIiL
County Parcel Identification No.(PIN) h t;,,ah`ca
51a.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
: ::: i tt, 1 Llrz
(ifWcll field,one latnong is sufficient) 22.Certification:
•
•
85' N tot W �, Ell/74, 1 4-j0 -taZ3
6.Is(arc)the walks): ermanent or ❑Temporary Muse of Cert(fied Wall ConunctorDatc
By signing this form,I hereby cart*that the well(s)was(here)constructed In accordance
7.Is this a repair to an existing well: ❑yes or Ti7Pfo with 154 NCAC.02C.0100 or 15ANCAC 02C.0200 iVell Construction Standards and that a
if this Is a repair,fill out known well construction inforntatlont and explain the nature of the copy of this record has been provided to the well owner.
repair corder#21 remarks section or on the back of this form. 23.Site diagram or additional well:details: •
1 You may use the back of this page to provide additional well site details or well
8.'Number of wells constructed: 0 40 construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. �� i 24.Submittal Instructions:
9.Total well depth below land surface: (ft,) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths IIfd Brent(example-3 n@200'and 1 100
Ca3 ) construction to the following:
10.Static water level below top of casing: 3 0" (ft.) Division of Water Quality,Information Processing Unit,
•
Ifwater level is above casing,use" I f 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: (5-1-a 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:
i
13.FOR WATER SUPPLY W); Division ofFVater Quality,Underground Injection Control Program,
d LLS ONLY: f' 1636 Mail Service Ceni ter,Raleigh,NC 27699-1636
/
13a.Yield(gpm) 5 Method of test: bL..t 24e.For Water Supply SeGeothermal 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: 19';6�; Amount:C1-(1� 2' completion of well construction to the,county health department of the county.
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013
i •