GW1--06627_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor I. f`Information: o
R '`, r"M\�l i l 4 1:14r1,VATL''R'ZONES - •. , ..:... ..ii
FROM TO DESCRIPTION�
Well Contractor Name �®ft. ' / ) )ft. / Ut. /_n 1
0.58 - A /6b ft /r+t0 ft. 1 16AL,
•
15..OUTERCASING(formulti aseil:ivells)'ORLINER(if up`hehle)NCWell Contractorficanon Nutber
VOa,i/ 6 WDie IA
FROM
/ ft. 1 TO�� ft. / //DIAMETER,iM ��jTt�nyCEQCNESS MATERIAL
Company Name p Nlt�/��� j p �
16ANNDR•CNSINGIORIDDING:(pentliaininl•eliiiid 4ciopY.A.
2,Well Construction Permit#: d � G FROM •TO DtAMETE : THICKNESS MATERIAL
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft ft. .,im
ft. ft. ,-ln
3.Well Use(check well use):
:,37:sextrEN ,_.`
Water Supply 1 Well: i :::.. >..•
PP Y FROM TO .,.i, DIAMET SLOT SIZE THICKNESS MATERIAL~
❑Agricultural ❑Municipal/Public •
f6 it la `'
OGeothermal(Heating/Cooling Supply) faftridential Water Supply(single) ft. ft, in.
t_is,•GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) i
❑Irrigation FROM • TO MATERIAL'. EMPLACEMENT hfETHOU&AMOUNT
0 ft. 07 y ft. Aye/pity
Non-Water Supply Well: �, d
❑Monitoring ❑Recovery ft. fr. I.
/19141°4
�Injection Well: ft. ft. _ �b165
❑Aquifer Recharge ❑GroundwaterRemediation A SAND/GRAYELTACINifarinli}:1�{lle ,:;: a;:,•.;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. fr. I
❑Aquifer Test
❑Stormwater Drainage .
❑Experimental Technology ❑Subsidence Control fr. ft.
%20:DRULLINGLOG'(attachadditlon l'abseis'ilueeessary)
FROM TO DESCRIPTION(color,harilness,solUrack .)...•.•r•
OGeothennal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fe• /'® ft. tyro amtn she eta)
4.Date Well(s)Completed: 5' /6 -c .o;t 3 /6 ft iraL ft. ,-1,,;; i 1
S.Well Location:
Careie I"torr"� /!_7 ft. /�a fL col: i&CLr Sf.�f<__
Facility/Owner Name �+t�tt ft
IQ }� ��••f� / �) p^ FacilirylD#(if applicable)
Physical Address,City,and Zip
ft. ft. =,. f>y rr d /kJ PICASItg+ s m
CAPjArt-Qa�S i ®, :z1.REMARlts _ !,a. L ' ' �l'` t�2 '`'`" ,. ..
J
County Parcel Identification No.(PIN)
I nevi r7,.`:-'.r.ni ter:c:,:: +,''Z,c,�! Un. ...
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)' 22.Certification: I u`+ea
35° 40'40 N 104t22 )J4( ��7�"
W �11 "�L.J
allure of Certified Well Contractor I Date
6.Is(are)the weli(s): crmanent or ❑Temporary h
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑yam or with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!phis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the tvoll Owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
•
You may use the back of this page to provide additional well site details or well
8.•Number of wells constructed: b AM_ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.SubtnittalInstructions: '
9.Total well depth below lend surface: I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdierent(example-3©200'and 2(0100) construction to the following:
10.Static water level below top of casing: 02 0#. (ft.) Division of Water Quality,Information Processing Unit,
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Ifwater level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �t t� �( above, also submit a copy of this form within 30 days of completion of well
r ff construction to the following:(i.e.auger,rotary,cable,direct push,etc.)
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)- / Method of test: /lrd 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
p the address(es)above, also submit one,'copy of this form within 30 days of
13b.Disinfection type: !At (e{3 Amount: ��,�,S 7t 4 completion of Well construction to the county health deptinment of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality
• RevisedJatt.2013
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