GW1--07775_Well Construction - GW1_20231201

W EJLIL CONSTRUCTIONRECORD(GW-1) For Internal Use Only:
•
1.Well Contractor InfoOrmatiolp: _ _-.
p
`' �'k dot// y'�K Ri-;1 1 ia:s ll rt. :a 1 ?r•r: { __ ..
14,=WATDIf 111v�S.- . f,. �x,.xti „ �•_ >,. ..
FROM TO OCRIPTION
Well Contractor Name ft. it. fiat y 023 5.142 As2
NC Well Contractor Certification Number "::1S,VOUllEirtie S1;Naffik t"7ilititeastH eli1)'7Rg?TI I(,i(ifd8p 11eld311) "-
figfir /fin// ,81-r6• t FROM TO DIAMETER, THICKNESS MATERIAL/s
Company Name l�cJ (i �•y ft. //D ft, /J I lin. ee 1� • /v f,Ee
)
P Y �y q `16/:-,1/1WER`.CA dS MIDR,T IBIN/G(t'ieattieniuiLabie +iiabii)Y t s..•:, •/1 •:, •:,.:•
2.Well Construction(Permit#:/az /3 /' FROM TO DIAMETER THICKNESS MATERIAL
• List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. I
ft. ft. in.
3.Well Use(check well use):
7'17:;SCREEN',:;fi 2_wr./.. :ecS,':4?4lWOAT.,;:ii: ,gr.*t. 'r 12'. sn : .:.: .
lWater Supply well: FROM TO DIAMETER SLOT SIZE ,THICKNESS ^MATERIAL
lI. Agricultural DM ,'cipaUPublic 0 ft• ft. in,
Geothermal(Heating/Cooling Supply) ijj, 'esidential Water Supply(single) ft. ft. in. •
Industrial/Commercial EjResidential Water Supply(shared) at. ..
e IBfGRQC7T+asa,nn : t}>_.,_�; w `x`. e: N.
Irri ation FROM TO MATERIAL E CEMENT METHODO &�A�M/OOUNT
Non-Water Supply Well: 0 ft. /79 ft. eerie/PiJ4 �/���`r=/!/07
Monitoring DRecovery ft. ft. e AO,
Injection Well: ft. ft.
Aquifer Recharge EiGroundwater Remediation �� ;.� ,
19::SANI1/GRA°VE1 PACK6tnPP1ieli6l4Mii:,� ;w. .d, .1;F a::M_,., r..:7+'. •
Aquifer Storage and Recovery Jr Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
Aquifer Test IStormwater Drainage ft. ft.
'Experimental Technology 0Subsidence Control ft. ft. ,
Geothermal(Closed Loop) j Tracer ;,2o:.DRIELILrlt;7;0: •(uttnblraildiderairelieiitsnf-,'n'eoessairyias i 'i+r r<. ',.• •
FROM. TO DESCRIPTION;or,olor,yç78'
,soil/racktype,grain size,ate.)
Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks) ft. ex/
4.Date Well(s)Completed JA Ob 7.?3 Well ID# I tips ft. / p ft. 9 70� ,7„6/�4/y/j-& ' -
Sa.Well Location: Y/®ft. 94 i. 41,Vim} 6%! l l t0
Facility/Owner Name Facility ID#(if applicable)
. c/Pe..A14 1 0d- C-h ii..' #e ft. ft. I 9Er J 1 2023
Physical Address,City,and Zip ft. ft. I l n
Ile- l I.
REMalucsl�
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/long is sufficient) 22.Certification:
e /p ,3,,p ;,7
rgnature of rtified Well Contract r Date
6.Is(Are)the well(s) a ermanent or Temporary
By signing this form,1 hereby certJ that the well(s)was(were)constructed in accordance
7.Its this a repair to an existing well: ]Yes or lialCre with ISA NCAC 02C.0100 or 15A 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 record has been provided to the well owner.
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
6.For Geoprobe/DPT or Closed-Loop 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. •,
drilled: ....0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r'Li 10 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3(Q200'on"'ta 100') construction to the following:
10.Static water level below top of casing: Li 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fp 0 (in.) 24b.For Injection-Welk: In addition to sending the form to the address in 24a
a� D � �� �� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /"* construction to the following:
(ix.auger.rotary.cable,direct push,etc.) I
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ll y0 et. 1636 Mail Service_Center,Raleigh,NC 27699-1636
13a.Yield(gpm) °�"-11� Method of test: Jro h� / 24c.For Water SuaDiv&Injection Wells; In addition to sending the form to
�I / the address(es) above, also submit one copy of this form within 30 days of
)13h.Disinfection type: 'th Amount:,(A a completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016