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Home My WebLink AboutGW1--07180_Well Construction - GW1_20231101 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Y�-d �A f} J - , , rAV � A� � M AR/St w 14 . litV axsT s>/°r:;:�' - FROM TO DESCRIPTION i Well Contractor Name ft. it. I, g I. 4 A • it. ft. I NC ellContcactorCertific tIoaNumber r� at R Si C..f�o1 t)yil'' 1Rdli►'eui)`• s (lt?ia ifai ie ! : • / I. / FROM TO Iws DIAMETER THICKNESS MATERAAI t �� a any)lY(� l__.o. L pi., 1 ft' m, SDi J P 1/G• Company I410 S11bii litCA8 1(UI,[Jtt11!1! i/KtIYe '114104 4 )i r/3 .'.x+1i619.?::�s:<> x;,- .-I/,�D?", �J O2 3.-203 f OM TO (DIAMETER THICKNESSMATERIAL 2.Well Construction Permit#: / O�' 44�� k, ft. ' t°• List all applicable well construction permits(I.e.UIC,County,Slate,Variance,etc.) In. ft, ft. 3.Well Use(check well use): , :^)l l��: f. (,t #ri'„ a c.;,,• ;.w, �, F .ay.,`.,k•.', = ivy!er`'^{'�1�'is:..'f+'e'e.!�k �v�-_'l.c�are•.:'t::i.:.� +�ltISMEN i('•.`^star .DI75 r 6" 4i• Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL � A cultural °Municipal/Public ft. ft• i in,Geothermal(Heating/Cooling Supply) ggResidential Water Supply(single) � i la.ft, y� yyu,'aK. ,f , } Residential Water Supply(shared) '" �} r. ... �ti r: tn=;tF� i r•d''u ''t' `:'_ PP Y f�X`e'3•,ORQ�'t+`I�'�i9. §;,:;`l, �">!'r i- s�� ct`c<<'..".sG',.";Y,...tu,.3��;fi�_.•, �,..:�Fi<�d,.,'•, Industrial/Commercial � ��" �°'�1�'''��!'` ' ' FROM TO MATERIAL} EMPLACEMENT METHOD&AMOUly7 Irrigation • G ft. fA �j Yl IeIil!.C /✓�Q�JS f2DGU e films Non-Water Supply_Well:,__ - _. -- .-- .—_ _-- -__. V--. /- Monitoring °Recovery' it. ft, Injection Well: ft. ft. Aquifer Recharge °Groundwater Remediation GAVE iPAit(ii Viiti dite)`1�'-'sVA:ti t;r"..:a f^t r�3A2 1wZ41;::`;914•`` 19iflAP37 EMPLACEMENT METHOD Aquifer Storage and Recovery ' °Salinity Barrier • FROM TO MATERIAL Aquifer Test •,' `• Q Stonnwater Drainage • tt, ft. gy ;'\• • [Subsidence Control ft ft. Experimental Technolo S, ' r _: ,, .i., ,r;;ryt!� x"S e Geothermal(Closed Loop) °Tracer 9JF tb (610;t0:0(aiWI Dd'dllllInol.O N(colt Wolin 1Z,t-t ck typ,grain toe :c FROM TO I DESCRIPTION(color,hardness,eolVrocV type,grain sloe,etc.) Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) D fp 69 g,I d! 'rt �!rl 4.Date Well(s)Completed: if)f AS`7"o i ID# 7 O if' .3 /Cit.i c.A ref-rut-6 ft. ft.! ; Sa.Well Location: r ft. n,I J ,',fi.y f;,i . ��K- Pi-ell/Le S Pf ��.✓ r ft. • tt.i . NOV � 1. 9Q23 ,..„,,,, , Facility/NJ iieer Names �� Facilityp ii(if applicable) 3 / /rJ' C �n_e 1 J 1\C�, ft. ft. ft C'� : .... ....,'0 lf„i . Physics Ad a,,City,and pip 5. e •r r coif, It's v e"i°yir,i.f�( '._i-, ..S'.. lei{... ;'.,r ."• County Parcel Identification No.(PIN) ` . 5b.Latitude and longitude ib degrees/minutes/seconds or decimal degrees:• ' 22.Certification:(if well field,one lat/loog is sufficient).3 68/ 94-4 N -� gt , Fc9614.E i W ` �� A...i.)„,,i) la --'Z6 Signature of Certified Well Contractor Data 6.Is(are)the well(s) Permanent Or °Temporary By signing this form,I hereby co.*that the well(s)was(were)constructed In accordanc 7.Is this a repair to au ixisting well: °Yes_ or lallo ---_- • - .- -wlrh.3SANCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that 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 welt owner. repair under 021 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 we 8.For Geon,on only 1 OW-1 or is Closed-Loop needed. irate O A NUMBER.s the elms construction details. You may also attach additional pages if necessary. construction, 1 GW 1 is Indicate TOTAL of wells SUBMITTAL INSTRUCTIONS drilled: /�- 9.Total well depth below land surface: • . f`J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of we p ) For mu$iple.weils list all depths(f di#erent(example-S a(�00aad 2 100 construction to the following: 10.Static water level below top of casing:! rJ�- (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: `� (in.) 24b.For Infection Wells: In addition to sending the form to-the address in 2e • above,also submit one copy of this form within 30 days of completion of we 12.Well construction method: V 1,CLr) 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 e, Method of test: GZ11" 24c.For Water Snooty•&Injection Wells: In addition to sending the form 13a.Yield(gpm) I the address(es) above, also submit one copy of this form within 30 days G 5 completion of well construction to the county health department of the pun136.Disinfection type: t D Y/Yi Q Amount: where constructed. . Revised 2 22-20 Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources .