GW1--07921_Well Construction - GW1_20231208

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,--' WELL CONSTRUCTION RECORD(GW-11 . For Internal Use Only: •
1.Well ntractor Infor ations t I
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Wall CoohaotarName - FROM TO
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411/5-A • ft. ft. ! j
• NC We�Contraotor Certification Nu Mbar n }jjt Y)?I ;IZ 11V Sf((b° `i •t i(5 5 '3 It( f + l 'u 71`' ''`"1
�� S 4 ,i /I�i�l ( 1 j��G FROM TO DIAMETER TRICKNESS MATERIAL
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Company Name II / �,j t�I• YNI!ISlNi '% t i mile' F116i tig v7ril�rf.ai�,3i1rlaa>�:tt
2,Well Construction Permit#t 0.F rT.3 Cp 1 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.)
ff, ft. j In,
ft. ft. In,
3.Well Use(check well use):
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Water Supply Wells FROM To DIAMETER BLOT SIZE THICKNESS MATERIAL
Agricultural OMunloipal/Publio ft. ft. I 1 In.
Geothermal(Beating/Cooling Supply) Residential Water Supply(single) ft. ft.
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1StY 71•flay ($J3ax�c. '+y 'iSiwr ,bsi''Ryt�it „''�Ul`tii±R$??`L�l .
iIndustcieVCommerolal ORosidentiel Water Supply(shared) (�XgilOgdt'1l��'�:�;.��1Y��5�/k•,�,���,« ,
Irrigation FROM TO MATERIAL EMPLACE METHOD&AMo
Non-Water Supply Well: O ro „up rt. hPi(c i�Li.k.fr S "tnAre4
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DMonitoring ORecovery It. ft. 0
Injection Well: ft. ft.
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DAquifer Recharge 0Groundwater Romediation i Ng„ ID � iP tl (A b� yll)i. w,ti ,•};T��JavY*t k4'si�'ti<1�� a Si."k-�4
Aquifer Storage and Recovery ' ' OSalinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test ' .\; \`. DStormwater Drainage • ft. it,
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Experimental Technology }",' ' [OSubaidenceControl ft. i.
RGeothermal(Closed Loop) `>;'' ` 0
Tracer PiAlic la rcrOi i ia`ePdditliffi illaiRfitaeli�ir)-tri't1Yi, •. l� ;Aih}r.:Kula;r
FROM TO' DESCRIPTION(w:ory 6erdetuj,alllrock type,groin dzo,etc.)
Geothermal(Heating/Cooling Return)�y Other(explain under#21 Remarks) D fA � ff, ,. I�/
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4.Date Well(s)Cgmpletedi' �1 -1-23 Well ID# 7� tG 1 ,Sit. ,, p-4jt
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Sa.Well Loeatigns , '
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• FaollitylOwnort mo / �F1aolUty IDIl(If applicable) • .-. A
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Physical ddross,City,and Zip {,.... ! .y,;..:;s;;;
t ' !nr:,r,-.2:z❑ : --.,_'; ' ii
. County • Parcel Identification No,(PIN),. .,,-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• -
(if well field,one lat/iong is suffiotent) 22,Ce�cation' / .
6-, 70t 7 N - el, qq455- W ,/ I mo . / m_-/-eZ3
6.Ie(are)the well(e)EPermaaent`'
Signature of Certified Well Contractor / Date
o� OTemporary
ay signing this jorm,I hereby core that the well(s)was(were)constructed In accordance
7,Is this a repair to an erdating well: ©Yee or ElNo with 13A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
I/'this Is a repair,Jill out known well.construction information and explain the nature oldie copy of this record has been provided to the well owner.
• repair under NI remarks section or on the back of this form. 23.Site diagram or additional well details:
— . - •• You may use the back of,this page to provide additional well site details or well
8,For Geoprobe/DPT OW-I or Closed-LOOP, eothermel Wells having the ells construction details, You may also attach additional'pages If necessary,
construction,only I is needed; Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTION$
9.Total well depth below land•surfaces i'5' (it.) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiplewells list all depths(fd(ferent(example-.3@20 and 2®l00) construction to the following:
10.Static water level below top of casing: ' '1.,0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above bas►ni,use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 Yik (in.) 24b.For Infection Welly l In addition to sending the form to The address in 24a
above,also•submit one dopy of this form within 30 days of completion of well
12.Well construction method: r O ta-Ny construction to the following:
(I,e,auger,rotary,cable,direct push,etc,) . Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall"Service Center,Raleigh,NC 27699.1636
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of'PO test: -/ �' 24c.For Water Sum&II&Infection Wells: In addition to sanding the form to
13a.Yield(gpm) Method Gc the address(es) above, also submit one copy of this form within 30 days of
G�1 D Nl Yf Amount: 02 Gi L{�5 completion of well oonstruotion to the county health department of the county
13b.Disinfection type: 1 whore constructed.
Form OW-I North Carolina Department ofBnviroamantal Quality-Division of Watet ResourcesRevised 2.22 2016