GW1--07940_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: t.
1.Well C?ntractor Information:
•
al<iW�Ao t atrovinv t titePt4Yr:a:i;�ltixf�:tl''?1{i s t..�7;;.�,�o��a,:..g;.���i
_�o /' _i)oLoid _ FROM TO I DESCRIPTION
WellCoet�eotorName ft. ft.
•
• NC Well Contractor CertiflcatlonNumber o'd;i";•'a Y T'e (tit >-ik;a;f *:' :.:17 fu)Tii.?i, I:-SAS .:'.Agir `;`:,.:4
-
FROM TO I D TER THICKNESS MATERIAL,
�i v12. s .i iJ 11 d">� Y�-m (icy�j vt�, 1 a,0 q.•t•<. in. ,./ gg s�'te,"1
Company MIA t� TUN'U ' .'c l?:i`' ci(o}`I1 1417 I'c fa''';..re'''.`: I; ; :,'•K i •11''111.7L.iii"i";t•t3..,:kVv
PROM TO • DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#s ft, it. in.List all applicable well construction permits(i.e.UIC,County,State,.Variance,etc.) In
• ft. ft,3.Well Use(check well use): • '.i ooff' C:•�� a is ,`•' W.w'41»F.:F�rS :'r '6..;..i"tk'. ,=11 ,',% 71`K</F;jTji1l;
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMuniotpal/Pablio ft, ft. In,
Geothermal(Heating/Cooling Supply) .Residential Water Supply(single) ft. it. In,
( ) ;i C. o •11:,•. '..r:,';,,y(a:1 nb a4,.:li•< :,,,l,.s,1:i; �:s>;H`yiiiti:•'.is+i ln;?,
Industrial/Commercial Reatdendal Water Supplyshared 4ys• '* - a.�av f`�,
Irrigation
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
� ,y
Non-Water Supply Well: ft' o 'q ft. b t?11rut I e, )Z Gt Qs— e,Lc re,
Monitoring Mr Recovery •' • ft• ft. v
Iniiction Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 'MVIIS' %GO`atiP (I lt8lliV40 I'3 kk +'./.L'a1040/M.,Vitg ti s`•0;
Aquifer Storage and Reooverjr ' . DSalinity Barrier . FROM TO it, MATERIAL,
EMPLACEMENT METHOD
:\ , •, \ \•
Aquifer Test a
• Stormwater Drainage . - ft.
. Experimental Technology";\ `,`,‘• DSubsidence Control ft. ft. .
• otlldi`tkiMit`'• QGIi'(i('0101fa'diililifdillnlatiit ettiti'i)lfi::i'i30i/'{,+';(?l,`;i~;iar 1•�';ii
Geothermal(Closed Loop) ' DTraoer FROM TO' . I' DESCrurnoN•wror,sheer,eolUrack type,grain laze,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) Q tt. �P qtt. 5 A n \J ,S r7/1 {'1'i x
4.Date Well(s)Completed: i J`1)71 Well ID# .t)0 ft. (�6' 3 !kji'11'i-7'
ft. ft.
eAni5a.Well Leptuift. ft,'Facility/OwnerNemo / horn 1'MN(If applicable) •
1.3 k, t� •w, }t, 0; 1
J (�b pun fir �j v �, ft. n. ���: J 8 1Pr
Physical ddrese,City,end Zip YsY.j _ ` ,"7::._ "'
F ! �d a gr,::1:,. Sv,..ili,v$N.v.: :.i�'^Ajl/;:),; ;..:.•..',tt.i:. �.'•
County Parcel Identification No,(gIN). .. I • +c1=;:\u
5b.Latitude and longitude lit degrees/minutes/seconds or decimal degrees:• • fion:
(if well field,one 1at/Iong is suffi 22.Certlflca
cient) II i+
•
,f.:I.g L7I % N '41' 91"Io1 13 w e i/-: ,/2- I-,2_3
6.Is(are)the well(e)EPermanenei :Ir.:DTemporary 8iltsature of Certified Well Coutreotor• Date
Baer
y signing ihls form,1hereby t(/y that the walks)was(were)constructed In accordar
7,Is this a repair to an existing well: DYes •or•Elm with 15A NCAC 02C.0100 or 154 MAC 02C.0200 Well Construction Standards and the
IJthis is a repair.Jill out known well constrUCNon information and explain the nature of the copy of this record has been provided to the well ower.
repair under 021 remarks section or on the back qJ fhlr form. 23.Site diagram or additional well details:
You may use the bank of this page provide additional w site details or w
8,For Geoprobe/DPT or Cloiaid-Luo(L.C.eothermal Wells having the same constructionumay i b, You may alsoa toa d [onal pages if well
necesdet
construction,only 1 OW-i is ne®dtid. Indicate TOTAL NUMBER of wells ���TTAL INSTRUCTIONS
drilled: • h j�' 1
9.Total well depth below land surfaces • . a 4-•1 (ft.) 24a.For MI Wells: Submit this form within 30 days of completion of w
For multiple.wells list all depths ifd(#erent(example-MOO'and 2®100') construction to the following:
'a
10.Static water level below top of casing:: �J 3' (ft.) t.
Division of Water Resources,Information Processing Unit,
(/'water level is above basing,use"+"' 1617 Mail Service Center,Raleigh,NC 27699-1617
' 11.Borehole diameter: t e f 4 (In.) 24b.For Iniectlon We Wells: In addition to sending the form to•the address in:
above,also•submit one loopy of this form within 30 days of completion of w
12.Well construction method: Y"n / 1 .-r l/ construction to the following:
(Lc'auger;rotary,cable,direct push,etc.) / Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai Service Center,Raleigh,NC 27699-1636
I
d Method of test: /�a 1'" 24c•f'ar Water Sunrrl1 BG IDlaetlen Wellal In addition to sending the form
13a,Yield(gpm) s(es) above,lalso submit one copy of this form within 30 days
13b.Disinfection types ,h I/I(. Amount: .2. completion of well constn:otion to the county health department of the con
where constructed.
' Revised 2-22-2
Form OWI North Carolina Department environmental Quality-Division of Water Resources