The URL can be used to link to this page

Home My WebLink AboutGW1--07929_Well Construction - GW1_20231208 „,WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: I :- 1.Well Contractor Information: L /� r A ,D r thin , : r -S �v_ ,� ,4 .a}y(- x,e•:�+: 'z:V,- .- 6i._-r C_l' �d� Q c_ (g411.� � •41N I h:�71,?A�irij�W.�S:,a!l't;:.�.lirFr.:;itch:t �5>y...ti:.ii;<+r:ir:`•�.:;, :.`.:• Well CootmctorName /) FROM TO DESCRIPTION 4 /� /� ft. ' ft. 5— 5A ft. ft. I • NC Well Contractor Certification Number ;`:10 'Rt SI 'if1(f t'lt.'+titile” ivellir113IiliD Rl? Illrilliii)i:"W,;.,'=° 0. nn J FROM TO DIAMETER THICKNESS MATERIAL Ce ps 1��J 1 -� J r�1 � _Inc. it. Y ir. t f -5-1°. so,e z, P V C Company Name f 1. i, h _3 S W o��-' ��'b�Tt;�4e' .�?lUlit')B .�t(��l(e".,iltAi3�oo�)'r,<�;;#1yF�'.�i`ririi:�,:r :n..... 2.Well Construction Permit#: (1) 140 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft., ft. in. • 3.Well Use(check well use):, ' , ft. ft. in. • Water Supply Well: s%I41;8(s >bki�b r-hnf yy �3rs3"rka? In;;t.Et-rdi, rr jar:.c2:��r.,,. R.:." PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural QMunialpal/Public ft. ft. ' in. I. Geothermal(Heating/Cooling Supply) p§Residential Water Supply(single) ft, f(, I • to. Industrial/Commercial 0 Residential Water Supply(shared) iolaltttitC.v M: ;.c e {04'.; r .'� y !i �i� a �zt �ru: - Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT . Non-Water Supply Well: Q ft. AO ft. .he,it.1�t' 14.bitiS D ccre,d Monitoring DRecovery - tr. it: - - Injection Well: • ft. ft. Aquifer Recharge "DGroundwater Remediation , _iail ,l . i 1911013D%G )`1tkIC A '( laili a�:�ii)?e0i Hi 014i;:iV tfMr. :: :,. Aquifer Storage and Recovery ' . DSalinityBarrier - FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test -ti. , 1 DStonnwater Drainage • ft. ft. Experimental Technology •'. • 'o' DSubsidence Control tt. ft, j Geothermal(Closed Loop) ''\ ' OTracer '�?4O 1Rklfl .Rssl q-'Cyr(a``(ta``b)(ra`ttilltliina'StiEW[:)te'b. ArS)1c`Y `r-di ::iiAi;?>;:%i. _•i' Geothermal(Heating/CoolingReturn) 0 (explain FROM TO' DESCRIPTION(color,Eardneu,mwrock type,grain elm,etc.) (Heatin Caolin Other ex lain under#21 Remarks) O tt. / ft. 1 D VN _ /V 4.Date Well(s)Completed: •/I o�-iZ3 Well ID# /1/,S ft' 6 D.f1 9 Y�.ni�•ee 5a.Well Location: -� • ft. ft. 1 -0A n I -1 - /; I o e , ft. ft. j: . •:.„.-�A,.•a.:y T >'a:: �. Facility/Owner Name I Facility ID#(If applicable) ft. ft. i• • n 11' /v 1 0014/1i/11LX5 _D r: ft. ft. ; . E 2.z, Physical Ad s,City,and Zip - ft. ft. ! I n t°.,t,r, :r,.n ,,,z4 4-II)mot:l I l 1ZEIY1 :IiER i!_- `...�,,:,17?4, %;fit-; .w,. .':..: .t-. i= 1` £$:C,--;fib; ';`ir...r,^�' �d;$rki* �k�:r .r.t.; :cX:xi.% County Parcel Identification No.(PIN)._ t ' 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• - (ifwell field,one lat/long ls.sufficient) 22.Certification: 54 r 3 N ��,l�l;�"S a w V/.de i/'-2.7-023 i 9lgaatura.afCerti Contractor Date 6.Is(are)thewell(s)fPermanent or DTemporary - di •By signing this form,I hereby cere.that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or MiNo with I5A NCAC 02C.0100 or-ISA NCAC 02C.0200fell 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#2I remarks section or on the back of this form. 23.Site diagram or additional well details: 8.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 i ay also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 0 (fh) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple.wells list all depths((different(example-3Q200'and 2QI00) construction to the following: 10.Static water level below'top of casing: ' (ft.) Division of Water Resources,Information Processing Unit, if water level Is above rasing,use"++" 1617 Mall Service Center,Raleigh,NC 27699-1617 11.Borehole dia-meter: 4 (in.) 24b.For Infection Wells: In addition to pending the form to the address in 24a above,also-submit one copylof this form within 30 days of completion of well 12.Well construction method: r� Gl-r� construction to the following:; - (i.e.auger,rotary,cable,direct push,etc.) ( j - Division of Water Resources,Underground Injection Control Program, - FOR WATER SUPPLY1WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a..Yield(gpm) J Method of test: Zl y' 24c.For Water Supply&Iniection Wells: In addition to sending the form to I- i r the address(es) above, also 'submit one copy of this form within 30 days of 13b.Disinfection type: G Irli D VI I •f C Amount: ),-- G(A./.6 5 completion of well construction to the county health department of the county where constructed. Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016