GW1--07213_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD(GW-11 For Internal Uae Oniy;
1.Well Contractor I orm Dion: '
Dail)a 1/) )ie\ - _ ?.,.1,,l•_4.?1' !o at;..110 2:',4:Inns•.',(d';rrd i.�i 3�tztVA 41 ;,.(', i:`�`ii .04-..W. avf.'
PROM TO DESCRIPTION
WollCooheatorName ft. ft.
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NC ell Contractor Certification Number �� "e �..�.C((dS'4 ;t f ilKti$ Ile •' ihi �lt(tK1AYtl1)IltA1ii)ilvu r, v.••,[;..,et
/ v�e-/l Co, y�G PROM TO DIAMETER THICKNESS MATERIAL
ft, ln.
Company Nadu `, ,o, // R4i6¢)1lbA+ CirA dtt? ' :11 oagiliikali'®}illifthtalllit5b1 miss!4l,z>;r"�b�?�i?at1
2.Well Construction Permit#: J�t��— b 2) tP FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta.)
B. it. . in,
• ft, ft. In,
3.Well Use(check well use):
Water Supply Well: •
e is. am S Amogo N f ! fwouwtGa :w
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • ©Munioipal/Publio ft. ft. ' . in,
Geothermal(Heating/Cooling Supply) INRes(dential Water Supply(single) ft, ft. ` I In,
Industrial/Commeroial DResidential Water Supply(shared) -'l :p;; 11.: 0.,.747.,.6,i,'"}t(4 a,,,"'''.,J4,:/1,';',os:1.:,; .;a :c.y7,'':i:jg0414; 4,
Irrigation FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNTM
Non-Water Supply Well: 29 it, /I6 tb beitael /- i511. 5_,ittfeCI►
Monitoring - . N Recovery ft. ft.
Injection Well: • to it.
Aquifer Recharge 0(3roundwater Remediattion ((Hy pbyl�Sg. ;;;Ti3;;I;! ?c'JaelAi l?+'siii,f�+tizxrir`tt,dz>`si
/ EMPLACEMENT METHOD
Aquifer Storage and Recovery ' ' 1��Salinity Barrier PROM TO MATERIAL
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Aquifer Test \t \) oStormwaterDrainage • ft. ft. ,
•Bxperimontal Technology •' •;:•.‘'`‘' QSubsidence Control ft. n.
` Tracer i� ol/[El? 1itrAfart tie alltlo�'il Ntit i ,etalri� !)T`:,5,'l3�/.i1;;,?lt ,;s_us1',c:��:;:,a t
Geothermal(Closed Loop) '`" [ FROM TO I DESCRIP I,Deolor,berdueu,WI/reek type,grain etre etc.)
:Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 12 tt, i,z4 f t. 1` --�''`�' e- I�Y
4,Date Well(s)completed: b!9 23 Well ID# ), Oft' .5 bJ -t' 4 jr-A_rtrf€;--,- ,7—
5a,Well Locatlon: ' `
I:e. )' )✓l1 4'k ffi h.. ft. ;, NOV t) St. 2023
ft.. : •
• Faolllty/OwnorNemo Fao�IDH��plloa le� _ •,r±•_
1 , u f` 1 Sr:l Vili�.i,•2': '...Y�', : Ur;
Phyaleal Addreae,City,and Ip ft. f ft. �p .cK F rr t.1 +'�ii%v.i+':`c'`;5'tt t'+'l" 'ti+ti:at�+','yiecl
-+ ,;ia.V $i4;t S ii;'iic'IN.,g!'� ;gil4 00111 h•:,..:tag e.... 5.0:::':0n•
1:;?/.
County Parcel IdontifloationNo.(PIN),. ,.
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5b.Latitude-and longitude iu degrees/minutes/seconds or decimal degrees[• ' 22.Certification:(ifwoll Sold,ono let/long Is sufficient) \ �' I '
5 1L).�9'I N R 1. 914q�4- w ` \/)Qi1� (` ! 1 l— —�
Blgnee of Certified Welt Contcaotor Date
6.Is(are)the well(s) Permaneni' 04Temporary
By signing this jorm,l hereby cert(/j+that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or NNo .with 1SA NC4C 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
(/this is a repair, ill out known we0.eonstruation information and explain the nature of the copy of this record has been provided to the well owner
repair under 1111 remarks-section or on the back gfthbjorm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Look ceothermal Wells having the same • You trumay use the back of this page to provide additional well site details or well
oonaon
construction,only 1 OW-1 is needed; oti details, You may also attach additional'pages if necessary.
Indicate TOTAL NUMBER of walla UB�,r,ra INSTRUCTIONS
drilled:
9.Total well depth below land surfaces3 (R') 24a.1+or MI Wells: Submit this form within 30 days of completion of well
For-:nultlple,welis list all depths((d(gerent(example-3@200'and 2®100) construction to the following:
30.Static water level below top of casings ' 6 (ft.) Division of Water Resources,Information Processing Unit,
{boater level Is above easing,use"+"YLI-
� 1617 Mall Service Center,Raleigh,NC 27699.1617the form
to•the address
il.Borehole dleineZe'rt �P (in.) fection submit one Wel copy of thins form sendingion to wlthin 0'days of completion o in well
12.Well construction method: r above,al o
da-Y� construction to the following:
(i.e.auger,rotary,cable,diroot push,etc.) . Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se r vice Center,Raleigh,NC 27699.1636
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Method of test: 2=1i 24c.For Water StlOD1y&IDIa2 Wells: of dddittiotnottons sending 30e d ys o
13a,Yield(gpm), l) the address(es) above, also;submit o copy
13b.Disinfection types �kl Drl YLe_ Amount: A. Ga.. completion of well conatruotion to the county health department of the county
where oonatruoted.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Reeouroea
• Revised 2-22-201f