GW1--06675_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inform don:
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Well Contractor Name FROM TO DESCRIPTION
at/(34. ft. ft.
ft. ft.
NC Well/► Contractor Certification Number //7) O 11.'011it,O(fdiifili)(l�egledtwelle t.rP )
lt-`LINER(It�iiii 11wr blil `�"i r
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fL n / 1-jl� V FROM TO DIAMETER THICKNESS MATERIAL
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Company Nante /� ✓
S f�1 ✓ 021
�/ 6S7fY1�TEIl'<QA C�'OR IifiBll!1Gr�(keu}he f l�oluleazlt►uit)2 P fci;x i 3 'F: s t ;to
2.Well Construction Permit#: l� FROM TO DIAMETER THICKNESS MATERIAL
List ail applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft. I In.
3.Well Use(check well use): ft. ft. In.
biffil'S.CREEN )ut^ s1 ?.t:'ie'Wi?tit+..G`.txo ,`l' ..A a'-z',-r 1Fia=MON. 1=F� i f
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ()Municipal/Public ft, ft. In.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ' g, I in.
Industrial/Commercial DResidential Water Supply(shared) tt tm� r=r ftSi rat u 4• : ir, ift:Y:' s., `�,:> �+
1'd`1g raR�.IJ0.17..:�'�.,�z3 5�t+ �>r�,�aYf,�'�"r__ :-wa„Jz*i:�t�: ;t.�...c�:YfkEY<
Irrigation FROM TO MATE EMPLACEMENT METHOD&AMO
Non-Water Supply Well: 0 ft. .02-9 ft. be ei -r F. ti.t4 Ells - uye-c
Monitoring - ()Recovery 'ft. ft. - / --
Injection Well: ft. ft.•
Aquifer Recharge ()Groundwater Remediation
491iSAl/CRA 'I.?PACKi(If apt tctble)t.,.<-. try. -a. ,„;r4w ' ;m s `...
Aquifer Storage and Recovery' ' ()Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD '
Aquifer Test '`. ` 0Stormwater Drainage ft. ft.
Experimental Technology `,.:.'... 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer z'20t?DRIliDDICrLOGI(a(tielitidilltloiiifilip"Ifni dciliifilti iks' 4Arlaci.-;'•:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TTO^/� DESCItiPTION(color,hardocu,ealUroc�,ty/pe,greln elze,etc)
j/ q O fL ,J% - ft. oIY•Ii( /aillGvgl/e/
4.Date Well(s)Completed: /Q-7"vl-3 Well ID# 66 ft. 4)5'ft. I e yanite J
•
5a.Well Location: I,, R. ft. `-
•&y cry to 1ta, �k YC,r6oh- ft. ft.
Facility/iWner Name /� Facility ID#(if applicable) ft. ft. ;' ' i.'', `, -
1b.5 b 1=re.e�rr ,- 1ZI. ft. ft. _ e •'•P'Y,.::.i' a:
Physical Address,City,and Zip i ft. ft O C T 1 7 2(72 q
l� `:2uREiHmacg ...{, .>.� �.or?x : .='ti 4 -u?
I/BEY I d r in n - ,1 :._
County Parcel Identification No.(PIN)
tom::�;_;0v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• •
(if well field,one llat/longgis sufficient) �// n / 22.Certific�atiion: ry
36. Ol J v2J Z3 N 1l t �� �lv � W f"` 7p to` 4 ` .z.7
6.Is(are)the wells) Permanent or'()Temporary Signature of Certified Well Con otor Date
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: DYes or ilitNo with 15A NCAC 02C.0100 or 15ANCAC 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 well owner.
repair under#2I remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
• I
9.Total well depth below land surface: 6 (ft.) 24a. For All Wells: Submit-this form within 30 days of completion of well
For multiple.wells list all depths((different(example-3®200'and 4)100) construction to the following: I
J
10.Static water level below top of casing: • 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
(- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6 I ek rV construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A-/; 24c.For Water Supply&Infection Wells: In addition to sending the form to
f i , the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C-h/o j i 1'i 6 Amount: ems--- completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016