GW1--07930_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ontractor Information:
tt !ixtrA#tlfl' 14%?Y A ► Y, r, A �r.,,,;�„�.��a>..M,
�Jl4t�A'+P�It�?Y!I�S?Ir:�`x � ��`;:li,�lti�f���/v'3ti��:d/,�•i�T;tis,�,,:.h.,...:.i,..y,.�,.:;.
�'Y r� �� FROM TO f DESCRIPTION
wolf Contractor Namo ft. ft. '
14 r LISA rt• .
31�k Yi!l rah
• NC Well Contraetor Certification Number r
�a • e':.0W( fX.i' A S!11)1(1131±k1 RT(11�4#1 g`A"'(:'/`""'"s""
FROM 0 1 !DIAMETER THICKNESS MATERIAL
f (/!/ !f I �N_h'1�0 ,f X. Et. ft i,t/,z.5 in, 6b K2-1 f' e
CompanyNeme // -fi.. ,.I! ;. , (e'o is, :AN'(il(t�1 e't (iiril5il 111 St(fry Ifipi ti3h; r',F-i,'t •
I4 1 _ ) Q 13 FROM TO ! DIAMETER§ THICKNESS MATERIAL
2.Well Construction Permit#: d— D, _ ft in,List all applicable well construction permits(?.e.UIC,Coun(P,Stare,.parlance,etc.) •
ft. ft: in. -
3.Well Use(check well use): Jr 410 13 4 ,,, •,i: +>P, .t. ,r,AO,J,M,f.Aiii.It
Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrioultural ©MunioipaVPublio ft. ft. In,
Geothermal(Heating/Cooling Supply) BlgResidfmtial Water Supply(single) ft, ft. to,
Industrial/Commercial QReeldantlal Water Supply(shared) WISI IIta•t I kea 'r'lyi'r<t O;'Y gh -;,f rx{`%4A,N,,W y' } :iP°"�'
Irrigation FROM TO I MATERIAL ' y EMPLACE THOD&AMOUN
Non-Water Supply Well: p ft. .o n' h en�eIll f°e 13 ))ctti. —pD/i.rt,
Monitoring - $Recovery It. ft. �J
Injection Well: • it. ft.
Aquifer Recharge QGroundwater Remediation . ,t Hg„ -/• y , utP Hsaa ntb .a gohs t,;,ti„0;,a?i r.ft1 ;kiullt>( ' `!g;:
Aquifer Storage and Recovery ' ' ©Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test •• . N.`. 0Stonnwater Drainage . ' ft. ft. ,
Experimental Teohnolo • ,';‘' Subsidence Control ft. ft.
P BYE:• t. Ailiil2lxllilt,is tt4pi- r 1 a 3 +::,;•:,.;
Geothermal(Closed Loop)' '` )Tracer 'e' ggI(g' DESCRIPTION
d O n barbs )il�:.ocll typ?,•r in size,
PROM TO' i, DE8 R1PrI0N(salary hatdnur,�olUtroeit typo,grain�lze,etc.)
.Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft, ss4 n, �a rQ✓�(f 1 a.y
4,Date Well(s)Completed: I 1—I�^ ell ID# ' )'—vft. „J D5 it. a j/ky,I fie„
ft. 1
5a.Well Location: . •
5.1`e. ve,26,-1t �r P.A & 1I ft. I.
;
Facility/Owner Name Facility IDN(If applicable)
. . • • l if(14iota]AS Dr. Lot,zo l � ft, ca n i(: of 8 7fc 3
Physieal Address,CI yl,and Zip 't�( yp�+•lA y y/�5 /([��,
nn L:.240Ke a , , i. 1 i•QY / :.,!rite'et-;i.{t+)1 tf c yy' ,v.ti:i • t
(JD l�(1 I v�A ¢. 1'.:i:r.t 5if,r,!.rfs:i.W i ii. 1/'F 115;R•
County Parcel IdenHBoationNo,tt!'U4 _ - I
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:• ' •
•
• (if well fie ,one lafnong is eufflolent) 22.Certification:
3 T / 51 N — /, q‘ 34 7 w • 1 /if 1' // �y-2-3
ontreotol Date
rn
6.Ie(are)the well(e) Permanent o� 8lgnatureofCertifiedWell Temporary By signing this form,I hereby care that the well(s)was(were)constructed In accorda
7.le this a repair to au existing well; -DYes or 13No with 1SA NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and tit
If this is a repair.pit out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under N21 remarks section or on the back Q(this form.- - 23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed=Leo . eothermal Wells having the same You may use the bank of this page to provide additional well site details or u
construction,only 1 OW 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: , — (fn) 24a.For All Wells:j Submit this form within 30 days of completion of v
For multlple.wells list all depths((different(example-3@200'and
//2®100') construction to the following: -
10.Static water level below top of casing: . �P J (ft.) Division oftWater Resources,Information Processing Unit,
Ifwater level Is above basing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
/ t 24b,For Infection W
11.Borehole dfeme4tirs. ells: In addition to sending the form to the address in;
[p `� (in,)
above,also.submit one,copy of this form within 30 days of completion of v
12.Well construction method; I,0/A-Y'y construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
24c,For Water Su IAty&Infection Wells: In addition to sending the fern
13a.Yield(gpm) J Method of test: �l r the address(es) above,!also submit one copy of this form within 30 days
13b.Disinfection types (`1 16 r1 hP✓ Amounts ,_ GLt_ .5 completion of well ooustruotIon to the county health department of the oou
/ where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Writer Resources
Revised 2.22 2