GW1--07928_Well Construction - GW1_20231208

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:'
1.Well Contractor Informs on: I •,
A r Y'ce l aVj �� CrtA1A ��YOrVt2� FrlPPr
v a tfYj w
Well ContreotorName _ FROM TO DESCRIPTION
21 (t. ft,
�L� S I ( ft. fti , •
• NC W I Contractor Certlftoetion Number ; y�a> pi ifl'( �,'� !eQ15 lit} 114WIS I IlfCd v'be i:``'.::::
I '''` FROM TO - I DIAMETER THICKNESS MATERIAL
Gi kvy\S //l/L 1 f Y �f�l4�l ���..4146... H- C q.h' j 6, I, �tn• 5 KNEE f: p l�AL
Company Name! q q • .-1fi hlone rgabatimbi 11!1otemlre (tlis'ii5it lYltic"li)i l iiiMi i 4 r',}>:s`tttti
2,Well Construction Permit#: V 0�02 /0 2/� FROM TO I 1 DIAMETER THICKNESS MATERIAL
in.Ides all applicable well construction permits(W.Ufa County,State,.Variance,eta) ft..
ft. ft. ; in, -
• 3.Well Use(check well use): y �4 y f l �} =.ri'
Iliilll0REE III;' iil1' a ter.?t It :+l4.41 1 ,I.3,1M31' airlila�1 ,;:gttfiA r it
Water Supply Wells FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrtoultttral ©MunloipaVPublic ft. ft. lu. I
toeothemtal(Heating/Cooling Supply) IBResidential Water Supply(single) it. ft. ; In,
Industrial/Commercial DResidentlal Water Supply(shared) WrIKpM�,tiqair p �� �ha .r A. �'r •Y t lof
e4,4
Irrigation FROM TO
MATERIAL EMPWCEMEtt METHOD&AMQUN
Non-Water Supply Well: G f t. 020 ft; b eiti�er'li�e i4 bMc - i D ai red
•
Monitoring Recovery - ft. . ft. �/ ?pared
•
Injection Well: - -- -- - - - - - -_ it. it,
Aquifer Recharge 0 Groundwater Romediation ;wi1,NSAf9tYM'At'➢OiSM t(tiip 011igR „4.0l"lies`iiMikl"si; 5's1%%Ial 'tf,
Aquifer Storage and Recovery ' ' ©Salinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test , \ ‘.\• 0Stormwater Drainage . • ft, ft, ,
BxperimentalTechnology,..•,,•.:'t:\' 0 Subsidence Control • It. it. '
a�J�4li15/1lt7li'L` 'Cs 1100XliitCog iadlilgddlli i$f181[ifaCii ".SC j i3i't's+!Irrrlt+,ilj }iN,I is
Geothermal(Closed Loop) 0Traoer '
FROM TO' I DESCRIPTION(color,6ardae ,mlVrock typo orate use,etc.)
Geothermal(Heating/Cooling/Return`) Other(explain under#21 Remarks) (G g A ft. i 'Loy -ij YOC v)f✓�l�'
4,Date Wells)Completed: ! I ' /-Z3 Well ID# ) D rt, . DS fit. LI rdtrl 1V
• ft, to
5Aon: .. j - .._:, .-. .-..
I o n ft. �. •/1 ft, ft, r.� L`� �� �-�� ��
�( l�� S w. t
Facility/OwaerName hie)) Faoillty LW/(If applicable)
. . • . /1 1`Kl ' kc1• lV e))6 t. ft. ' DEC 0 g 2n-3
i it. [L
Physical Ad oss,City,andglp {/�{(5}�}� } ',[,+""' ' i� ) �, ,,_ ti .
MDt'w). .1) :«'s, :i ip::.xis''u nlf.lif2i,:-.:..?Cii,.ti:'.;14.. `.I w
County ParcelIdentifcationNo.(PIN1- -
5b,Latitude and longitude fn degrees/minutes/seconds or decimal degrees:• .- -
-
(If well field,one lallong is sufficient)• 22.Certification: 1,
g J` cn P�' '� N got, 0 l '7 W 4/4'�'`(c 2 ,%% 8, `•—,2
8ignaturo of Certified Well Contractor Date
6.Ie(are)the well(s)SPermanent ' oh. DTemporary _
Sy signing this form,I hereby eertilP at the wells)was(were)constructed In aecordar
7,la this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 134 NCAC 02C.0200 Well Construction Standards and tha
If this Is a repalr,Jill oul 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 book q/'this forts. 23.Site diagram or additional well details;
8.For Geoprobe/DPT or Closed-Leo .G4 eothermal Wells having the same You may use the back of this page to provide additional well site details or w
construction,only I OW I is needed.•Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages If necessary,
. . drilled: pUBMITTAL INSTRUCTIONS
9,Total well depth below land surf:ices 1 (ft•) 24a. For MI Wells: I Submit this form within 30 days of completion of w
For multlple.wells list all depths(fdWerent(example-8 a@200'and 2@100) construction to the following:
10.Static water level below top of casing:: 6 P 1) (ft.) Division of Water Resources,Information Processing Unit,
{f water level is above basing,use"+" • 1617 MI E;Servlce Center,Raleigh,NC 27699-1617
11.Boreholb dfaine'ter: (P!`1 (In•) 24b,For Infection Wells: In addition to sending the form to-the address in 2
above,also submit one Copy of this form within 30 days of completion of w
12.Well construction method: rb I. -r y construction to the following:
(Le.auger,rotary,cable,direct push,eto,)
•
Division of Water,R®sources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: e
1636 Mail,Service Center,Raleigh,NC 27699.1636
4 Method of test: .0--/ N 24c.For Water Sunnly&Inledtion.Wells: In addition to sending the form
13a,Yield(gpm) the address(es) above, also submit one copy of this form within 30 days
13b.Disinfection type: LrII l f o v t n e.. Amount: a GGL completion of well construction to the county health department of the cow
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-21
L