GW1--07178_Well Construction - GW1_20231101

• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
I✓ILI/I ` a- i E4'i4.�i A2FjRt.'�1�I' Ili 3S v .ez�FlW`.$ '-`fi'��.r.'•^�iti`a'pia`''i9ita':i 1. •y,:r ,d,i
FROM TO DESCRIPTION
Welt Contractor Name /
. -/.?ID 4 ft. 1
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• NC Well ontractor Certification Number::4-PHAS Aia V4/1-by 6, In.c. 1011 L'ERG`ASI[Vl(foc inulil=caiCilGwells);OIts1;1NERz(lf+aR lldpble)r .,',::%'
FROM TO DIAMETER THICKNESS MATERIAL
Company Name/ n �` ?"gg e :ii
// �� sl6iilliiNER# 18IP]6lORII!1lyTeotlteitiintsela'e"d;lutiii)k s i�x;+xn y'.e' u
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use):
14fiSCREEN3�:rrti I!`?::/ ,�: 'S4 r"14+',�.tik�,`rr%i'n`44>o i r' `-:1: � i g e Y=S
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [ 'Municipal/Public ft. ft. ' In
Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single) ft. ft, In.
Industrial/Commercial ['Residential Water Supply(shared) i4ltiiaRAYTiIs'�br0 tM };„ Va„ral ,k_hr f<<?
-- - Irrigation - _ _ , FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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Non-Water Supply Well: a ft. A-6 ft' pje' ti t& j li Sj�Sys-16 b t.0 Y�'d
Monitoring , ['Recovery ft. ft. 1
Injection Well: ft. ft.
Aquifer Recharge ['Groundwater Remediation NoffSAND''infv!rz pmddi+'iiiiig asle)ti0 1? r ay % aif`}'
Aquifer Storage and Recovery ['Salinity Barrier FROM TO • MATERIAL ,EMPLACEMENT METHOD
Aquifer Test 1 0 Stormwater Drainage ft. ft.
Experimental Technology ,`a:"\ ©Subsidence Control ft. R.
Geothermal(Closed Loop) ['Tracer ii20c:DRILIONt'rl o:Gr(ettacli kildittoiiilioligetiiiGtiieeesialiy) /. •4"M •ri.a h✓
FROM TO DESCRIPTION(color,hardness,reWrnck type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft. J�'
I 22 !� `�q C�•/1''7 G.-/ez.y
4.Date Well(s)Completed: Ie 7 AVell ID# t0 ft' it/5'ft. GI}^A-144/&
ft. ft. J •=
5a.Well Location: 4.i .' � � r._,.-. .:,.
,,,-;-;--.7,,,
ReK/�.F''t S h-a u m ft. ft. -4,., r--:.i; 'i? a,r ;
Facility/Owner Name Facility ID#(if applicable) ft. ft. i . NOV J i 2(173
1D/I Giy kJ e, L-{'i-. Pe /(i`lie 6r ft. ft. i
c
rti. g t;t
Physical Address,City, d Zip + id AZ) e
,I e ve 1 a- {`J f":mlGusto rsoi4,: i..z. .t7c.n_'tf-'"h': :t ?f. :n 40 r ,w,oy ..4,
County Parcel Identification No.(PIN) - - -
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • '
(if well field,one lat/long is sufficient) 22.Certification:
/0-.4.5--oz.3
, ,,6-: 1-4 .13-5-65. N -Pl. 6 .36-g 16" w x7i/ji,ip 4
Signature of Certified traeto Date
..6.Is(are)the well(s)DPermanent _ 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: DYes or 1§No with 15A NCAC 02C.0100 or 15A NCAC 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Lapp Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
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drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 4e (fL) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths if different(example-3(at200'and 2(4)100) construction to the following: ,
10.Static water level below top of casing:' cca (ft.) • Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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•11.Borehole dial]; (i 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: • V( if-r V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) /0 Method of test: 11—I. i'' 24c.For Water Supply&Inlection Wells: In addition to sending the form to
I the address(es) above, also!submit ono copy of this form within 30 days of
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13b.Disinfection type: CA-I.0)41 YL.. Amount: Gu-1.< 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
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