GW1--07226_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: I
r l'' ,o, i t: 41'I t'XYi'1.'.7,1•.l.•:�i'tt ..G§�4'.2 -ir. i4i3'r',,. �';. .it .if:,
�at/r a nz� "R.M .
FROM TO DESCRIPTION
�,WallCao6ueo"t{or^�"Name ft. ft. I ;
• NC Well Contractor Certification Number o d. o iNri(c e f to .;ii;I fs -.e II)b•fti'i's 1• I•'r.}`fl-- t vv ' " ..
�St
nU� Co, FROM TO ' DIAMETER Ty��C g MATERIAL
� -.•��•.,•
�a 5 live lI an c>< ` l! r� cj 3 R. i l25 In. P1 'X 1 ly lJ
Compen)YNemd 'O ;. •'omit°• ,: I.0i.l`Ckeli`e`.;palifia l i?s ilitKViitA ig.WiR
2.Well Construction Permit#:,C 2 l O / 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc) ft.. ft. 1 '
in,
• ff. ft. i . In.
3,Well Use(check well use); .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCKNESS MATERIAL
Agricultural DMunioipal/Publio ft. ft. , •in.
Geothermal(Heating/Cooling Supply) aiResidential Water Supply(single) ft. B. : to.
Industrial/Commercial DResidential Water Supply(shared) -: .6-. o.'i)!i 6; ,r.rY,; tor, r - „Al.,,,eg•`y,.:i,: ,:,,, . ,•0ra'4+,t}.Ii `• •
Irrigation FROM TO yyMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ZO ft. i ),447)t fE. 10 1304 Gas L%ooarp '
Monitoring •Recovery • •
U. ft.
Injection Well: rt.- ft. -
Aquifer Recharge DGtoundwater Remediation ar,.7.r•7/ :1)..,,w-Re. °r(l imipi -'t,)'% (,fow<I ,..i4,Y,a,•xi ii E's r/.'• sr:;f j°;:esi.,
Aquifer Storage and Recovery ' Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
Aquifer Teat '•� \ 1 DStormwater Drainage • ft, ft. , .
Experimental Technology ..,'.•,..`,,• DSubsidence Control ft. ft.
' Geothermal(Closed Loop) -•`'' ' DTracer it?' •11F.T ;tee:a•i a• dl•.•• 107'_.'"ee&t:Ary)tittf,l6is;:,,..':;sly.?.,;5kii:i .
FROM TO' DESCRIPTION(calor,hcrdaeu,toll/rock type,grain e:ze,etc.)
Geothermal(Heating/Cooling Return) IN Other(explain under#21 Remarks) I ft. i LI g, C.,.(1 G, y .
4.Date Well(s)Completeti:O OVZ Well DV b 5 ft. �8J ft. O' (,1/.‘ , R .
aA 'I ✓ -
Sa Weil Location: ft. ft. 1 ----' rr x
we. e7,^0t� J ti���I C� {�t3eA? o p ft. � ft. NO 2023
Fa(clllity/OwnerNamo /�/� n • )FacilityID#((iit'appltoable)
. 2.0 CtYl 12T+ /Y/�i /✓ i t-k� ` ft. ft. lrtici r ari;i �) C1.,;-.
�^" ft. , ft. Ot=;C:.; 0:3
Physical Ad City,and Zip _ �.a.;;a
P A':III �i/~l'•lyd.'64.:%ifi.�•.•b•.il'.:: .%Ii1V;;;.{:=:tt.l�.4.,1,: ,Jr•;:';::'�;5if �'l::S';:i.K. !24::R:i
MO PO KIP)i
1.
County Parcel Identification No.(PIN),, -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• • .
(If well Sold,one lat/long is suflolont) 22.Ce
X s4s7y N -Vl, 9e'g5 . W / ; ///`-.,23
ture.of Corti ed Wall Contrao' Date
•
6.Is(are)the wells) Permanent`' or.OTemporary -
Sy signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 13No with 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
,{/•this is a repair,Jill out iowwn well construction information and explain thenature ofthe copy of this record has been provided to the well owner.
' repair under#21 remarks section or on the back of thlr form. 23.Site diagram or additional well details;
8.For Geo robe/DPT or Closed-Luc eothermal Wells having the same . You may use the back of this page to provide additional well site details or well
p 1' construction details. You may also attach additional pages if necessary.
construction,only 1 GW-11g needed; Indicate TOTAL NUMBER of wells ;
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 U . 24a.For MI Wells: Submit 5. (it.) it:this form within 30 days of completion of well
For multiple.wells list all depths(fd(gerent(example-3(rr)200'and 2@l00') construction to the following
it
10.Static water level below top of casing:' • (ft.) Division of Water Resources,Information Processing Unit,
1f water level Is above'castng,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lam) (In.) 24b.For Infection Wells: 1n addition to sending the form to-the address in 24a
f�_CA above,also submit ono copy of this form within 30 days of completion of well
12.Well construction method; • �l( 'i r y 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 i Center,Raleigh,NC 27699-1636
of test; C 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method : ./-} the address(es) above, also submit one copy of this form within 30 days of
C.`(Jar'i lie. Amount: completion of well construction to the county health department of the county
136.Disinfection type: where oonstruoted.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
1. Revised 2-22-2016
I