GW1--07758_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:lE
C ntractor Informally?:
1.Well
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Wail Contractor N'tme! nn
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• NC Well Contractor CertificatiSon N/u/mbar p , / o d"'�"'•'o-1(:'i Cl
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Company Name .i ., • . .c;o 7 iTr;IY.c 0 uF • ;r-;.;"E, a
2,Well Construction Permit#:
List all applicable well construction permits(Le,UIC,County,State,Variance,etc.)
3.Well Use(check well use):
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrioultural QMunicipal/Pubiio ft, ft, `; i In.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) IL ft. 1 to,
Industrial/Commercial DReriidential Water Supply(shared) .h Z e•• ,1 , •,,,;/'Ai.1. :, (•,t„g Z;;;:.,:':,�,,;= .,y,3.e`n("`..:g �r``,
Irrigation FROM TO ,MATERIAL EMPLACEMENT METHOD&AMO
Non-Water Supply Well: 1 it' <gb n' 3enteni t. 1_6 )313_6— ,e Ar
Monitoring QRecovery n. ft.
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Injection Well: ft: ft.
Aquifer Recharge QGroundwaterRemediation t 1 ,� < =`aA
11 SAPlI�%(4'°r%9if�iR'A Zlt3R111111i`�li#$)5:;"s:;;gt� k„r:ii f:iit��-kh"sit�s��ir s:;..,� t
Aquifer Storage and Recovery ` ' QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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Aquifer Test . •., N. 1 0 Stormwater Drainage • ft. ft. '
Experimental Teclmology •,,,1:,:•;,`.‘' 0 Subsidence Control ft. ft' ,
Geothermal(Closed Loop) \ l' QTraoer
it t•Tr.1c6-10. .k tailYIV di•1 IP,. •eeFte )'r ' ai;'::;tra,'50:/ii:; L ',
FROM - TO' DESCRIPTION(rotor,herdoeu,mlVraele tYPe,grain etc.)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) D.
it, �p g, d 1) a� 1 s�h
4.Date Well(s)Completed: // 9 Well 1D# (70 ft. 4l�6-IL 6f-yu ,
ft, ft.
5a.Well Location: ��I• r --
A i‘ Aft. ft. i..^ �.._ :T ..�•
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Facility ID#(If applicable) k' fA Y„�
Facility/Owner Name
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Nl�rl<� h. ft. iL.tt.
Physical Address ity,and 7ri .:. j :• _° � ' v. ,K,�? ;<
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;$({ice"D`•l :� .is,: :�•i.,:r:: n`rt.` �:Rl...2 ..E;�s��'•'. . .....
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County Parcel Identification No.(PIN) -. -
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degreest• • 4
(if well field,one let/long is sufficient)• 22.Certification:
S 4'54Qq N •4.A-, 1)69 / f w lE IlI -'23
t Signature of Certifiedoatiaoto Det
6.Ie(are)the well(s) Permanent orTemporary '
• By signing this form,I hereby certify that the weli(s)was(were)constructed in accordance
7.Ia this a repair to an existing well: DYes. or 11No '. -. _with 15r1 NCAQ 02C'.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a,
If this is a repair.fill out known well construction information and explain the nature of the copy of this►ecord has been provided to the well owner.
`repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loo•Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
• construction only 1 GW-I is needed. Ind ate TOTAL NUMBER of wells construction details. You;may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfrtce: D 5— (ft) 24a.For MI Wells: Submit this form within 30 days of completion of well
FormuRiple.wells list all depths((different(example-.3@2200'and 2©100) construction to the following:
ft. Division of Water Resources,Information Processing Unit,
{10.Netr lStatic waterisabove level below top of casting: • �('Q • (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
{f water level u casing,use"+"( • f
11.Borehole dlame4tir: �� (in,) 24b.For InIeclon Wells: 'In addition to sending the form to•the address in 24a
-�— above,also submit one Copy of this form within 30 days of completion of well
12.Well construction method: I 9�D 1 CL}"l� construction to the following:
(i.e.auger,rotary,cable,direct push,ate.) ( It
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma1IIService Center,Raleigh,NC 27699-1636
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Method of test: Q-1 Y' 24c.F'or Water Sunolvi&'Inlection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
a2(�i S completion of well construction to the county health department of the county
13b.Disinfection type: ��. D)^�y(� Amount: where constructed. -
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2 22-2016