GW1--07915_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Information:
1.Well(t)ractor Inf / -
d _ PROM TO 1 I DESCRIPTION
IL ft:WellCont
Jro�otorNeme
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• NC ii Contractor CerttfloatioaNumber 7 .r O d,I• '(O,W i•t(c t�''''��"S(?UJ"`:.1`'l• .ii (or ly.o-6 '(r((:(I,.1'(A.ioc.,.'"•.,,:::.:
/g A ( .' I FROM- TO DIAMETER TWCitNESB MATERIAL
l/.(%� /IJ �c �,) rn�, �. •�. '�r, a6 tn. �nRzi PVC •
Company Nam j / - ,ci it (�•x-i c OW Via` N' is v., ,'e`;S is N' '" '. :f J .111 4. AO,;Huai.:..:;.?`.
•Wit.- -.F �� a D PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#t r// tt, it. t"�
List all applicable well construction permits(i.e.UIC,County,State,.Variance,etc.) In
3.Well Use(check well use); • ft. ft.f•;.e..��,. .,1� r'`1zn :1-A. i;7 ;'�;::•.aF '4, •24A..... % e / •
., k� ! •-%,i Ke fir.1,il}i6.;':yi•i.y11
Water Supply Weil: • PROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural ©MunioipaVPablic ft. ft. in. ,
Geothermal(Heating/Cooling Supply) FiljReswdential Water Supply(single) ft. ft. • to.
Industrial/Commercial QRealdential Water Supply(shared) rQ. ,0);(;"`fie@.:Y)':Cr%'iv,ply.'I.Ai'-tt, �`w' ;.:'•) •ordc, :,' .«Prwlt,4
Irrigation FROM TO I MATERIAL y_ EMPLACEMENT METHOD&AMOUN
Non-Water Supply Well: Q it. �G fit. Lnre rc 1 e, I g ))j.S "�fD 6 GLYE.o
Monitoring- II Recovery II. ft.
Injection Well: ft. D.
Aquifer Recharge Doroundwater Romediation K9 g„ Yf311r1'�'I l t'�^ EMPLACEMENT METHOD
l (t RIAL)>�)p.�3'i1}it u); a?� t�^i�'t'il y'u's�' ;`l"`!
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Aquifer Storage and Reoovbry ' Salinity Barrier FROM ft. TO it,
Aquifer Test ' `. • %\. 0Stormwater Drainage '
Experimental Technology.:•..,,...:',:';‘' DSubsidenceControl ft ft.
El Tracer 'f+•%YIU:G kit `?iiniftittliillUllli k iiiiG`k'eeiiiA )ieli lie--1.04.01 Wi
Geothermal(Closed Loci)) '' • QTraoer FROM TO I DESCRiPTION(calor,hordoeu,toll/rock type, In size,etc.)
. Geothermal(Heating/Cooling Return) IN Other(explain under#21 Remarks) D it. � [8. d,/r ;- .5 ii-t iJ Y6til�!
Completed: I--/-.)-. Well ID# h-b fa.4 -61n., vial i fta.
4,Date Wells) 1
. 5a,Well Laced° : dt. tt it.
Facility ID#(if ap Iloeblo) ft. It.
FaolUtylOwaerNamoI'tt. Ci t'' U 8 Zn-1
i. To c. Re1. l�8xt to G 5-I . h. ,,ft: ,;:,,;. .
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Phyalo oaa,City,end Zi Lo f 4 1• .2 'l f si'•''ifs:.�i..iw.'`'':`iiiiF' ".(lt;vigt?!`s?f';.$-;•i�c'�1s�;i:::yh!vr:i :ice:..
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County Parcel IdentificationNo..(PIN).- .
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:•• �y 22.Certification:
(If well field,el one leNong Is suftiolent) •
ftet.,
3J, 4916 N ' 2), ('.1J ! ) // W I• i it-)✓.0Z
8igaehuo of CertifiedWelf Contreotor Date
6.Is(aro)the well(e) Permenent o� Temporary
By signing this form,I hereby cert{fy that the well(s)was(were)constructed in accord
- 7.Is this a repair to an otdsting-well; DYes -or pliNo with ISA NCAC 02C.0100 or 1JA NCAC 02C.0100.Well Construction Standards and 11
r(fthis is a repair,fill out lmo'wn well construction information and explain the nature ojthe copy of this record has been provided to the well owner.
repair under N11 remarb section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page provide additional well site details or
8.For Gcoprobe/DPT or Closed-Loo1l.leothermal Wells having the same construction the
You may alsoa toap d additional pages if neooedet
construction,only I GW 1 is needed, Indicate TOTAL NUMBER of wells � TT�INSTRUCTIONS
•
9.Total well depth below land surface:. (it.) 24a. For All Well : •Submit this form within 30 days of completion of
For mulliple•wells list all depths(f d(7'erent(exainple-3@200'and 2©100) construction to the following:
10.Static water level below top of casing:' g d (ft,) i.
Division of Water Resources,Information Processing Unit,
((water level is above casing,use'/+,' 1617 Mall Service Center,Raleigh,NC 27699.1617
11.Borehole dfameltir: S `'•r • (in.) 24b.For Infection vt'euss In addition to sending the form to•the address it
�(-- above,also.submit;one copy of this form within 30 days of completion of
•
12.Well construction method: -rt7 l -4Y construction to the i l."i wing:
Resources,
(ire.auger,rotary,cable,direct push,slot) Division of Water Underground Injection Control Program
• FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699.1636
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of test:• / 2tic.Fly Wr Suabl
atey&IDfectio11 Wells: In addition to sending the fot
13a.Yield(gpen) MethodU the address(es) above, also submit one copy of th(s form within 30 da;
f7 I 1 C°. Amounts completion of well oonstruotion to the county health department of the of
{' __ LLI�S where conatruoted.
136.Disinfection type( � .
I' • • Revised 2-22
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources