GW1--07237_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:; •
1.WellC�'ontractgr I orma ens ..
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ia/ p 'I'IFrh', R 1410 t te-1:1 ,.el,m •O r.. s,t�u.}: .:
- — 4 �1f�. Ql.t;11- aYf.'�rt,' .4(:1��4e�S� i7#1 .. ..d,: .�:ti.:a:`.'Yaxq.t:. i'::�.i..a7:•1.•.
OM TO I DESCRIPTION
Wall Contractor Name fA ft: i
i3‘ A ft. ft:
• NC W I Contractor Certlficatf a Number ed Yjt ygR or tli`tsii'C y ; .tt`+ sedi atti) ]timellow iiY 1�o,-0 .. '`:''
e` I r J 1 CoFROM TO I DIAMETER THICKNESS MATERIAL
Gt vi E1 l P2P l�/�1 `Lnc• ft, 3 :ft' �t,�ln. ��/`�a Y G
Company Na)Nam / - -t / Ik16 It i t kl ,ate if aria gem-alum lu til4tar Fi! y,1,.L:x ;.....u!
2.Well Construction Permit#: / J • -_.- D FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UlC,County,State,Variance,etc) ' ft'
•
3.Well Use(check well use): R. �� in.E'1 M PAR(. /`•�,,,_..AWAtia .;,°�+f/f.F.hl,a.; t#i ilig aF .ilia ;iK0
Water Supply Well: FROM TO (DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©Munioipal/Publio ft. ft. ! ' In.
°Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft, I I to,
Qlndustrial/Commerc(al DResidentlal Water Supply(shared) -SOW. I;t?;lyt MAAgr,Y;)eFtiMAei`Iligititti5r va"Ott• ;t/r n?f'i`tx°kt lz:Yrii ;;;:`g
"Irrigation FROM . TO` 1 'MATERIAL. EMPLACEMENT METHOD&AMgUNT
• Non-Water Supply Well: © ft. dKw fG� b i.r l 14 b.t S-pou.red•
Monitoring _ _ Recovery ft. . ft.
Injection Well: It. ft.
gAuIfor Recharge 0 Groundwater Remediation 1985' yO) k t)PA ' Z($iq�'a11�ii8lb)4 i ;ilsit�t:^i; w�+'`dl k+"�;u'�slrwRz a<i g t
Aquifer Storage and Recovery ' Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test : . \ `•. 13StormwaterDrainage • ft. ft., •
°Experimental Technology . ' 0 Subsidence Control ft. ft.
°Geothermal(Closed Loop)% ' ' • DTraoer • a�J O;fD'BgI!'tq`t+T. q:Gf)((tip`d)tfd'difltl6gl?illAtilG`fiee.b{i4i;l!)Cs '.+ 'r;y>?%.sfic,:•`f;_.<
FROM TO' DESCRIPTION(color,be. oew n, olli &type,groin elze.etc.)
°Oeothetmel(Heating/Cooling Return) InOther(explain under#21.Remarks) - a ft, 54 i ft,i , 91 Y /1 .yam 41a-y l 1 X
4.Date Well(s)Completed: ! 1p a3 Well ID# .1j ft. j toc .! it Litt e----- ---
Sa.Well Location: ft. ft.I' r,..: .Lam.•3..F V Ej�,a J
1✓� SA. P12;I 1 i` s . ft. . , NO V , s 2023
Facility/Owner Name f Facility ID#(if applicable) •ft, ft.!
l)1 N tLh ,n, ,.,,.:;,: ,
Physical Address,City,` and Zip ft. r ft.,
(IIP Vek--A-Ci V.243l:il:l008by":%;si•.'f{`'.f:V.:`-,::se l•Kliigte'Ii;l; i140; Sij•!..;.j..:1. q;.!
County Parcel Identification No.(PIN) - .. •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• • .
•
(If wall field,one lat/long Is sufficient) 22.Ce cation: ,�
5, 1 gaN -S1. 4-02.7zS w 1 • 1`✓ 7-# .
t Sigaature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent ' or Temporary j
By signing this form,I hereby cert((y that the well(s)was(were)constructed in accordance
7.Is this a repair-to an existing well: DYes or IffiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that c
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
' repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
8,For Gcoprobe/DPT or Closed:Loo(r Geothermal Wells having the same You may use the back of this page to provide additional well site details or wet:
construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. Youmay also attach additional pages if necessary.
. drilled: .— :SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a 5 (it.) 24a. For MI Wells: Submit this form within 30 days of completion of wet
For multiple.wells list all depths((different(example-3©200'and 2Q100) construction to the following:
10.Static water level below top of easing: • 4 5 (ft.) Division of Water Resources,Information Processing Unit,
(/water level is above hasink use"+"(/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dietitian /y (in.) 24b.For Infection Wens: In addition to sending the form to the address in 241
12.Well construction method: rb tCL-rl above,also submit ono copy of this form within 30 days of completion of wel
construction to the following:
(i.e.auger,rotary,cable,direct push,eto.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) s5 Method of test: -(e'V' 24c.)+'or Water Sum,ly&IDlectlon-Wells: In addition to sending the form tc
t the address(ea) above, also'submit one copy of this form within 30 days d
13b.Disinfection type: 4)o v vie_ Amount: a-C..S completion of well conatiuction to the county health department of the count;
where constructed.
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2011