GW1--07786_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD(GW-I)/ . .
For Internal Use Only:
1.Well Contractor Informs on: ,
` `` C4`Iq�i1W/�hilll>1 1ws torn 371`YtYr ;ivi`s��r N?�,wl(i`�{ ifi;:tn f +.i ,'- .1 %;ix
•U a.tJ) ,g {�p UIROM TO DESCRIPTION
Well Contractor Nemo / - ft. ft. l
13 6 ft. ft. i ;
• NC Well Contractor Certification Number ' •51004 0CeeliBf I sff((bYPOW3 1 'e )t 0 WLINENVISII. 411. '"'"`�`:::,:"'V
Cf FROM TO DIAMETER THICKNESS MATERIAL
�s �� 1 Pak?, ' ft. q •'f<. 6/./.2s1n. •) 2.2,1 p c
Well Construction
/ Z1s191?�umi inir(s mi?sdy CSJYItf.g. �3�55i`i51'.tro a soar: >'tt�L,
2.'Well Construction Permit#: 1 �d FROM TO DIAMETER THICKNESS MATERIAL
tt, ft. ln.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) !n
3.Well Use(check well use): it. �� gg y ��{ pt N 4f/S•r h' wst '/�`.:%:jw'
kg ,)'• Yf f54�[L4�.:.4Y7',}{'¢{l\�{3rit^<l ,d}+..'Su t,OtJ''�},,Y::'1,t`l,':'F:U.
Water Supply Well: FROM RED TO•'a t �'T DIAMETER ` SLOT SIZE 'THICKNESS MATERIAL
Agricultural DMunicipaVPublio ft. ft. I ! In.
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. :I In,
Industrial/Commercial DResidential Water Supply(shared) 3.40toolgotm, ;'" %io rr 5, L'n A thmpl l;;jkel} >r ;cois i ' `bs .
FROM TO MATE EMPLACEMENT METHOD&AMO
IrrigationteIL ft. b - -- i9D lA_r-
Non-Water Supply Well: e�20 °L�lt phi �� �f
Monitoring [Recovery • ft. ft.
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation Kati liNDIGIA` 1P`A` (Ift4`AR11s 1316)%U:a+1;IF°1,K's:ARNM+sa y','sTw:.xaa,'•''`ti-ii
Aquifer Storage and Recovery ` ' IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \N. OStormwater Drainage • ft. ft. ,
Experimental Technology ',.' QSubsidence Control ft. ft. ; ;
AtifiDR `SICA'Q.(t� OVOli.fiffidltl$l iniilate1 i`11000`r)Cs i:,Ki.s!!k?f,.l;•rlir'.�).it'
Geothermal(Closed Loop) OTraoer FROM TO' �DE, S�ON(wlor,hardness,eotUrocY type,grain du,etc.)
)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D ft. • ._q t. , L!(}Qjt
r mkt;1-4.Date Wells)Completed:•/�'"'��".�.� Well ID# �D ft' �02�f G /.��y� e._
ft. ft. ,
Sa.Well Location: • / ft. ft. c...
.4. -! M'a 15 d .01/z ft. ft. `! ;•'�*. 'I P-s �,�
Facility/Owner Name Facility ID#(if applicable) ryry ""
ft. ft. • J=' t 7023
Physical Address,City,and ft. ',.it'.{.77r.3.5i,., ,
• 1'•.'1l1:?RR+�•tif�:4F'�`r'IS},:1'isia<.'Pi:,5nt:.gc�.[V31a,.i..!
��D`5�1�YZ- NJ.T.,vl,
County Parcel Identification No.(PIN)... . •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• • • .
(if well field,one lat/long is sufficient) 22.Certification: ' •
8. 1 I N gI, ‘ �v�3 �t► ( pC 1. IS . 303
'• i • Slgnativaof Certified Well Confreotor Data
6.Is(are)thewall(s) Permanent ` orTemporary
By signing this form,!hereby cert(jy that-the well(s)was(weraJ constructed in accordance
7,Is this a repair to an existing well: DYes or ENo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner..
repair under#21 remarks section or on the back of Ihisform. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-LOo geothermal Wells having the same You may use the back of this page to provide additional wall site details or well
p 1?
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
•
• drilled: / ,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multlple.wells list all depths((different(example-3@200'and 2®100) construction to the following:i •
10.Static water level below top of cueing: • _Co (ft.) Division of Watl r,Resources,Information Processing Unit,
Ulmer level is above Casing,use"+" 1617 Mall 8ervice Center,Raleigh,NC 27699-1617
f 1 � �
11.Borehole dlameler: /1 (In.) 24b.Jror Infection 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: r i tit- construction to the following:
(i•e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control ogram,
FOR WATER SUPPLY WELLS ONLY: ) 1636 Mail Service Center,Raleigh,NC 27699-1636
3 Method of test: ( 24c.For Water Sunuly&Inlection Wells: In addition to sending the form to
13a.Yield(gpm) Q )" the address(es) above, also!submit one copy of this form within 30 days of
f�`JOY)Y1-. Amount: (RGf-f - completion of well constiubtion to the county health department of the county
13b.Disinfection type: where constructed.
.
Revised 2-22-2016
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resource?