GW1--06670_Well Construction - GW1_20231017

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WELL CONSTRUCTION RECORD •
This form can be used for single or multiple wells For Internal Use ONLY:
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1.Well Contractor Information:
tc �L M. M ( 1 S •t.I4.:WA.TRRZONGS,s:.::?•.y.,...'•;t._,.. :
r\A . FROM TO DESCRIPTION :••
Well Contractor Name ft
,� ► 300 it 3a.o II .
Lc aL c5 / ,pi j �. Let_, bei f( t i Q�J `lac, ft- y io ft- �1
NC Well Conlrador CartiScalJi�on Number .i5::OUTRR CASING'(for'multi-cuuscil wells)OR LaNER'(if up'lienble)• �s.. .."•..• ... •::
a3 8 — !1 FROM TO DIAMETER THICKNESS MATERIAL
it. ; $(7 fttry in 5D a ! PVC
Company,Name `:I6ANNER•CASING''arruDING:(pcotliaenid,eiiied=log)• ;:i•?:;`
Q f I��' FROM TO DIAMETER THICKNESS MATERIAL •_2.Well Construction Permit#: ft ft. to
List all applicable well construction permits(.e Caa,O;Stare,Variance,etc.)
it. ft i in.
3.Well Use(check well use):
:,:17:SCREENt='..'.:':;';i;'ip:>':•.:; •..:ra,S..^'..,:•••::°..:i.u.`,i:i:i::i.., '.r ::.y :`.••_:,'S:,`
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mum' ipal/Public Fr. in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. se /in
❑Industrial/Commercial ❑Residential Water Supply(shared) '<ffiO_GMR OUT:T'O *•.,:..:. :h}'L TER: .. • .:.EM::P L A. ChIENT h1ETIlOU 3�AMOUNT`❑Irrigation
Non Water Supply Well: O ft. •2 5 ft. $fin i 4'on,.-}2 gored: 9 Inc s
❑Monitoring ❑Recovery ft. `7 ft" Ch' .5
Injection Well: it. fL t�,
❑Aquifer Recharge ❑GroundwaterRemediation .:19:SAND/GRA'VEI1PACIC=Ur ilieriblc) :__:`t_+•...:',; r.•:;; : ,:•. r..;,:.:_: ,,,;;;.-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT mutton
f. rt.
❑Aquifer Test
❑Storntwater Drainage .
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) °Tracer "•20:DRILLING LOG'•(otIacli'nddiddrinl•sbcetS ifri'ecodsary')''•":i;'a... >; : •:;....:.:.;:.:
FROM TO DESCRIPTION(colon hardnesIs,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. It 0 fa'
�h SOi •
4,Date Wells)Completed: OC -,R S' -c' 0a3 t10 fr. so ff. V(�COfl5ortd4.1.ed ?dLKr
5.Well Location: •
So it' 4 O ft, 5O i! a I��tl c is
PI lri4-�qo ft. bU ft. co,SLc!
Facility/OwnerNamc RQ tt. W�O ft, C� t4 •
Facility ION(tfapplicable 1 J t< ,••-., ,_„_ , _
�',3 4i 898A-P s Rd M 1(11 mA itc , ft ft. c. . �'
Physical Address;City,and Zip ft. ft. i n r T 7 n.
i'� L C tJ b l tt`('� ;21AtBrvI.12T[5 ... f.:* .. .... ?',,,,Q4:.Y.: :':202::; .. . ...,
County `J ParcelideutificationNo.(PIN) !r%''r'�`=`" ' t) ^ - t!-.
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D°a
Orwell-field,one 1at/long is sufficient). 22.Certification: o4
6.Is(are)the well(s): crmanent or °Temporary MfiudW2clm i Date '
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
• with ISA NCAC 02C.0100 or 15ANCACI
7.Is this a repair to an existing well: ❑yam or 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 wall owner.
repair under 02l remarks section or on the back of23.Site diagram or additional well d
thisorm.
form.
8.Number of wells constructed:
0 iJ:k You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For umltple injection or non-Water supply swells ONLY with the same construction,you can
submit one form. ,�j 24.Submittal Instructions:
.9.Total well depth below land surface: 'T 41) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths IIfdierent(example-3Q200'and 2 r 100
0 construction to the following: ;
10.Static water level below top of casing: 3 el 1.
If water level is above casing,use"+" (ft.) Division of Water Quality,Information Processing Unit, '
t i 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1
-[(tn.) 24b.For Iniectinrr Wells: In addition to sending the form to the address in 24a
12.Well construction method: fv�/ 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
� A
13a.Yield(gpm) `3` Method of test: rt I g. 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
`—T',�t` �� _ the address(es) above, also submit One copy of this foam within 30 days of
13b.Disinfection type: ll '4 i •e�Amount: tS /9../. completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department ofEnvirattmetti and Natural Resources-Division o£Watcr Quality
Revised Jan.2013
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