GW1--06628_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I
1.Well Contractor Information:
'L k'4.Q- R e 1\1- `I i-5
FROM .TO DESCRIPTION
Well Contractor Name VO ft. /6,D ft. 2
GMT.
1 �r�� ` `� 1.
L t()elks+• Lavt.� £ LJ {✓R;I 1 t 41 /et,ft. ISio ft. as,G,AL,.
NC Well Contractor Cenifiratton Number :,,15'OUTER'CASING`(formulti=cascda`velliMRL'INER'(if'ail-Neale)-.7.,"•:; •-":;;:;:..
Cy O 38 . A FROM TO DIAMETER •
THICKNESS MATE1IAL
Company Name •161:INNER"CASINGIOR OBING:(geotliciaial!ela5ed loop)
•
CA
.,. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. . fr. 1
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft, ft in.
3.Well Use(check well use):
.47.:SCREEN¢ r^q r,
Water Supply Well: FROM_ TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ptt'esidential Water Supply(single) ft. ft. ht.
❑Industrial/Commercial ❑Residential Water Supply(shared) . 1&;'GROUT , t;:' ••
❑Irrigatiott FROM TO AtATERlAL EMPLACEM1tENT MfETHOU&AMOUNT
Non-Water Supply Well: Q ft. • ft. �JDJGP1t-�9 I'�u
❑Monitoring ❑Recovery fr. ft. f• v t�O reci
/��
Injection Well: ft. ft. Q�
❑Aquifer Recharge ❑Groundwater Remediation ?.19;SAND/GRAVEli•PAClC•(if•anp )`.. . vlicnbte
l7Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL! EMPLACEMEN METHOD
❑Aquifer Test ❑Stormwater Drainage ft' ft. i
❑Experimental Technology ❑Subsidence Control ft, ft. ,
❑Geothermal(Closed Loop) ❑Tracer 'a0.'DRILLING LOG(6ttdch`nBditionuhshcets.ituties miff- °' •
,
FROM TO DESCRIPTION(color,haduns,soNrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) eil ft. a O ft. .4 o
4.Date Well(s)Completed: .`tl Z �.� /.� fr. �e ft. �r�XotJ T n z��
5.Well Location: tr. 5a tr. O,L I d e O C .
oil rA ft 6--A ft. G,gs ed .LJ e lt
�Sfrim. C ft `L fr.
Facility/Owner Name Facility lDO(if applicable)
`�� /7 ���'� �0�
//.r0 `Ear�shArdtZhop 4--01s,.$ ft. ft. .e r: ?
au+ 'T 11.v 1 ,17 A .r Physical Address,City,and Zip
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;121_1:101Altlts ;;'
�AdAeras CO , firT°'� r2p ,
County
Parcel Identification No.(PIN) U
RA
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: a1
35 02 "13 N SOk. tea'1 W • f ( A 1b- .3
� turn of Certified Well Contractor Dote 6.Is(arc)the well(s): tiii' maneut or ❑Temporary
By signing this form;I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or g with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out know;well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
Xi 6.
may use the back of this page to provide additional well site details or well
8.'Number of wells constructed: 0/V 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.Submittal Instructions:
9.Total well depth below land surface: 1 -r�•
(ft.) c .For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3Q200'and 1Q100) construction to the following:
,(Or
10.Static water level below top of casing: -7 (ft) Division of Water Quality,Information Processing Unit,If water level is above casing,rise"t" 1617 Mail Service Center,Raleigh,NC 27699-1617 II
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�t�-1'Ary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) a Method of test: r r �
24c.For Water.Sunpiv&Geothermal Wells: In addition to sending the form to
I7
�y-� . the address(es) above, also submit onel.copy of this form within 30'days of
13b.Disinfection type: !��I(as Amount f s- 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 tY Revised Jan.2013