GW1--07212_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD (GW 1) For Internal Use On1y
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1.Well C ntractor Information:
4,r Y P, �GL�'/(�t° C 'A1)S�t1 ►1r c7 SFJ't t 5'/v Jl`=;k�Y«:+;i.�i m l'?�vl;' s:;s'71 n�if::j s:'.l vt:,i<•y.
Well Contractor Name ! LIROM t� TO 1 DESCRIPTION
.4� 5--4 vV h. tt;
• NC Contractor Certification /� )� J n1 ;O1f ,Rtasso( µ),i)*; bdfiemt 1ti`I'rlt iltli )Iflin :l'v.i L'''.'ktI:::•
Q J i 6) I Plivi'/t J / FROM T i I DIAMETER' W J Ra I /� vC
/d• s'YC Go /f ft, ft: )/ in.
Company Nam r l l'b#tl iR1omar tOIi Yl)!T ►a 1C@gdtllgt'•z�fliQll}it 'Arlo ) ..,-KO/.0?r R S zi r;
2.Well Construction Permit#: •• 14�-I -- •� /6 FROM TO ' •DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,Slate,Variance,etc) ft.. ft
in,
•
3.Well Use(check well use): ft. ft ! in.
is' 2v..,,, ova, '• ,. C,tv.4..A't,- ,kil4,46., .1 `-;mJj1%av_.I►)IiSrF;/Sil ik
Water Supply Well: FROM TO !DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrioultural 10Muniolpal/Publio ft, ft. 1 i in.
Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft. ft. l- , in.
IndustriaUCommercial QResldential Water Supply(shared) ^a v„ * �r�c t•?ea?r* a vq,:. .��•s''"-
�xfBll;(9Xi07Ull� �iil.��`�:.�si4 i �f:�,��.,��--'r}j.�4 .�:tl�:';���<�<�x�;�.,vrw�',��.�
Irrigation FROM TO I MATERIAL ` EMPLACEMENT METHOD&AMOVNT
Non-Water Supply Well: 0 ft' Ad ft.', b�:re nl/i'. i 14b 5 ! D caret
Monitoring QRecovery ft. ft.
Injection Well: ft. ft, .
Aquifer Recharge QGroundwater Remediation
fliVISArroagovaalt' i(lit nllcad SI w`-+1r?�ti�li i3Stif �v',a�si,lta%-'!"_%
Aquifer Storage and Recovery ' Salinity Barrier FROM TO M4rERIAII EMPLACEMENT METHOD •
Aquifer Test \ \ \ c3Stormweter Drainage ft. ft.
• Experimental Technology-.; ',:',,,' 0 Subsidence Control • ft. R.
Geothermal(Closed Loop). OTracer • 'dJI4IJ71 Cs,R'QSs 60ttleJ'ttallilBillndl?dirt!$/ irlfecaiarv)1 011: ?:Irt'0,,ls;'.Mw,;1.
FROM - TO' 1. DESCRIPTION(color,hardness,mlVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) <
p re. 5'9 ft.I`` cir fl iNaLv e'1 1v-1 X
4,Date Well(s)Completed: 1i -,,23 Well ID# 0 fb . 4.5 fh l' ', 4{'G(121 te.
5a.Well Location: ft. ft.Y !(J
Pl,til1 Al re ) lulu,-ram ft. ft.I
}� y I i1
Facili Owner me Fa�illtylD#(ifapplicable) ft' ft.1 NI1V if 2`'Z1
l tw b 1/ S r H t."4� R ft. ft.I'
Pbyalo ddr�eis,City,and
Zip D` `�' ...,,.
K"—,/l it 1 P r 1,':�11.t'.. �r " .......l:�s`r l>;'7:i1k••a.••.tiYie.`:i,t!{.S1�r: !'3:i1i,`, tS.e:;:�.i',':s%. .::':i:so..•i'6ir
County Parcel Identification No.(PIN)._ �, •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• • -
(if well field,ono let/long is sufficient) 22.Certification:
36' )f9� i6, N — -1, 17 .'3o W ./fin 11-1-.2-3
6.Is(are)the well(s)61Permanent • or [Temporary Signature of Certified Well Contraotor Data
By signing this form,I hereby cl rtl) that the well(s)was(were)constructed in accordanc
7.Is this a repair to an existing well: DYes or MINo with 15ANCAC 02C.0100 or,ISA NCAC 02C.0200 Well Construction Standards and that
If this Is a repair.J►ll out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.• 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Luo(H eothermal Wells having the same You May uee the back of this page to provide additional well site details or viol
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages If necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 `1 (ft•) 24a.For All Wells: Submit this form within 30 days of completion of wel
For multiple.wells list all depths(ifd(gerent(example-3®200'and 2®I00) construction to the following:
10.Static water level below top of easing: TO (ft.) Division of Water!Resources,Information Processing Unit,
If water level Is above casing,use"+" 1617 Mall Servlee Center,Raleigh,NC 27699-1617
11.Borehole dlameltir: LP YA4- (In.) 24b.For Injection Wells: Tn addition to sending the form to the address in 24
'^ above,also•submit ono copy,of this form within 30 days of completion of we:
12.Well construction method: / D &I''11 construction to the follow/n g
di
(i.e.auger,rotary,cable, mot push,etc.) /
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
li
13a.Yield(gpm) I U • Method of test: d L I it' 24c.)+'or Water Sunnly&Infection Wells: In addition to sending the form t
the address(es) above, also;submit one copy of this form within 30 days c
A
13b.Disinfection type: C kl 0 Y i)a L' Amount: oC. G 1. 5 completion of well cons i orlon to the county health department of the count
where constructed.
Form OW-I
North Carolina Department of Environmental Quality-Division of Water i Resources Revised 2-22-201