GW1--07233_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only;
1.Well Co
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WellContractorName FROM TO DESCRIPTION
ft. H.
/15 6 A ft. ft. 1
• NC Well antractor Certification umber . •
n�{o axiom f(((d to,1 �A IK toot)Eli) t . ti lltt''v' '`'';_t`:::..4,14
A- M-p-6. eA) t P tt-)41-10 L Ii 4 .
f� , FROM TO DIAMETER THICKNESIL MATERIAL
Company Name / 'r'<ti
P Y /�. a *> ItX�``:�,(�1�l(NllyAil'ni'G11C@i�d'e •` (lliol$tt71:15oh)i�7�t1�-ht;'di,,ai�,:rl'='��ti;*.-`.Lrx
2.Well Construction Permit#: I -r / / / M - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft.. ft. ' in.
• ft. ft. In.
3.Well Use(check well use):
1►ia190/1 , �ARRE;I SE`:.SIVv IN it;„;l'iMAIL 64A-f•;"tai rag! ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
JAgrioultural ©Municipal/Publio ft. ft. I ' In.
Geothermal(Heating/Cooling Supply) gi Residential Water Supply(single) ft. ft, I In,
]1ndustriaVCommercial Residential Water Supply(shared) aw r t�•, rrz�{i� ' " �;, t§'' E.'}F "s
`—� � llltb�i(��t*?��'�i7:��Y�t-,�i.:�ir����),.t�;:�.:d�:�,..�Y,.�'�,,-tr�si��:<$i�� �''i��;;:�:n,
Irrigation FROM TO MATERIAL [EMPLACEMENT METHOD&AMO
Non-Water Supply Well: d ft. LL0 ft' b P-ilt c;( 15 bAAS—'751.tr
Monitoring QRecovery ft. ft. `/
Injection Well: it. ft.,.
Aquifer Recharge 0 Groundwater RemediaHon •
19 ' / N.,. 0110,' ( I 'd . • l),44,11.1ttA ...ir,;W kko/4' al'4.0°«5.'.--1
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test . • N. ‘`. QStormwaterDrainage • ft. ft,; •
. DExpetimental Technology •.\. ','' Q Subsidence Control it. ft.1,
0 Geothermal(Closed Loop)'' . • • OTracer 94;IlliD Ukl(aftliayiallHi"tt8udil►fl€tltittiaReiiill)C ::1<3ti;,ii•'Rfr tK41.r
FROM To 'DESCRIPTION(valor,barium,soli/rock type,'graIn NW,etc.)
OGeothermal(Heating/CoolingReturn) Other(explain under#21Remarks)• b ft. o`Qn' C /
4.Date Well(s)Com PI
pleted: J"h '9-3 WellID# • ,,soft' 4 f Ott'1 9 r 4_yL, fe.
5a.Well Location: ft. ft.;' ,‘—,. *..F. Y„ -
•
1\e...A Mt,it k e k ,j't. ft. ft.; .1,.Li.Fi,.,,'fi�.�i' it i1�0.,6)
Facility/Owner Name Facility UM(if applicable) •ft. ft.? N 0 V 4 ,; 9923
.3.,9,D old L,kV1-y/Gi RA• ft, ft.
n ft. ft. IfLvii„%.-:�cn ;ter- 57,: :g UnCi
Physical ddres/a,City,and Zip ,,••;r<�.� `
.7 to/ k. i��il:!o�'fuTP {vl<,f. t'.`y::t,. s t Sll.i?''•ii fifo:::?.':•=5'`_: -";{••
i+'f.+ '•1..:t:. itiP.r'•�!.fitt.!qa. .f.' ...b;:�. :r::;:.,.
Parcel IdeaHficationNo.(PIN) _
County
5b,Latitude and longitude i6 degrees/minutes/seconds or decimal degrees:• '
(if well field,one lat/long is sufficient) 22.Certlicatfon: 1
3 2-))1- 74 N '1 1024 1 w I Ciwy lI. 7—Z3
• t : Signature of Certified Well Contractor Date
6.Is(sre)the well(s)11Permanent or LjTemporary •
- By signing this form,I hereby cart th+-that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or MINo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repaint!!!out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under i121.remarks section or on the back of this form.- 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Lao$ eothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled; pUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' t' � (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multtple.wells list all depths if dioirent(example-3©200'and 2©100' construction to the following:
10.Static water level below top of casing: • G c" (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" • 1617 Mail Service Center,Raleigh,NC 27699-1617
t 1 '
11.Borehole diameter: 1s (in) 24b.For Infection Wells: In addition to sending the'form to-the address in 24e
above,also.submit one loopy of this form within 30 days of completion of well
12.Well construction method: r 01—CLY 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 Center,Raleigh,NC 27699-1636
�Q L( I N 24c,For Water Suunly&Injection Wells: In addition to sending the form tc
13a.Yield(gpm) Method of test: the address(es) above,f alao submit one copy of this form within 30 days of
rr ++ l completion of well construction to the county health department of the count)
13b.Disinfection type: di 1 O Y 1 Yi Amount: G� where constructed.
Form OW-I •
North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-201 t
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