GW1--01107_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well t�9 ntractor Info matt A /J'
.. ILr i'( / „J „I _ - r 1 i91T7► li1'.0gi;:'f.i t(:_;i.::.yrt,;; ;.'
• FROM TO iDESCRIPTION
WoIlContrectorNeme ft, ft. I
gb 4-5A ft. ft. i
NC W I Contractor Certification Number a1.5„01h1�7R'. N$11Gror';iriS(({ 9ItWlfs);Ulit111NR((�' dllcNlh);
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� ( ,� ��v7 T FROM TO 'DIAMETER THICKNESS. MATERIAL
('fy an S l��l V �L�F'" �,/ L 12�i, ft, Tle O 4 ft, 6 ,l DIAMETER
in. .S 1K N SS I .`e V .
Company Nan* • `.1'btitfek1031A1010'4011 . II!Crai0'ti�0-1kaliMat1RIG: ) :/A.: • .•
2.Well Construction Permit#: ' ' -•/ — `) 'j j FROM. TO (DIAMETER THICKNESS "MATERIAL
List all applicable well construction permits(i.e,U/C,County,State,Variance,etc.) ft, ft, I In. .
ft, ft. i In.
jifl>/,
3.Well Use(check well use): y.-
ilgOluJ -.:WA-�:;•.:a::PS:i`v):=it4,pi:,);•,,#:?4;.a%.:,,,,,.;.,::—::.:•.•..,..::.::.....•
Water Supply Well: FROM TO DIAMETER` SLOT SIZE THICKNESS MATERIAL
Agricultural :I Municipal/Public ft, ft. In.
Geothermal(Heating/Cooling Supply) EResidentlal Water Supply(single) it, ft. I In. .
lndustriaUCommercial DResidential Water Supply(shared) m8 61;5i!t;. v*.:t� `�:.:v.;s-;:,-A,°r"4�::.ti:L::0;�° ,• ,, `•:rV. :%;:'>;`:,w�:,:: °..
;Irrigation FROM TO iMATERiAL /- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' a.b ft' JjCnf�° /� }�D dyed" )� t�J fi
Monitoring- _ ,. Recovery, ft. ft. /
Injection Well: ft, ft.
. ;Aquifer Recharge DGroundwater Remediation :;: ...
''s.=t19�t04ill/01101YLkA'Q1((IftupPPII0ab16) :2•;rif; r:,,:::•.;......EMPLACEMENT
.•::•:,•.::. .
Aquifer Storage and Recovery . OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \. '. DStormwater Drainage ft. ft.
Experimental Technology . •,,.••\, OSubsidence Control ft. ft. .
Geothermal(Closed Loop)5'''.' DTracer i 20;i0R1lifftri1Gil;p:C'(aEfao)i?Rdd liiiaalilh'e.'tetl'f(tii3'u aaeiNC;r:'••<• ':::•. • ...:.-.:• ' • .
FROM TO/ it j� ft. /� ft. J1 N LrO�ol�r,h�rdne GL✓ )type,�yi)�e,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) (/ DE 7 1 Y
4.Date Well(s)ComQleted: Well ID# )0 tj 1• 1 Rs-ft, rX./ led
ft. ft.
Sa.Well Location; . . //� r/ �/ ( (
17'1,.-`("1^c,1.*It aAr /.ii4i -4- kip? ))hd ft. It. • NJ..;ka V E,L
Facility/Owner Name r . Facility lDll(If applicable) ft. ft. F E u j L ZoLrF
,,
/0 e it P(u V/e Li) D . P
10GCY) yL ft. ft.
Physical Address,City,and Ya>-5 1 yL-•• ft. ft. infcri .g4io n?r^^.F£ ;•;may U:.
County Parcel Identification No.(PIN)-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; .
(If well field,one lat/long Is sufficient) 22.Certifl tion:
Ay)4i7irf. . . 1- ),2_- .i-)
6.Is(are)the well(s) Permanelit 1 t drTemporary
Signature of Certified Well Contractor Date
. .By signing this form.I hereby cern&that the wells)was(were)constructed in accordance
7,18 this a repair to an existing well: DYes or nNo with 1JA NCAC 02C.0100 or ISA NC/IC 02C.0200 Well Construction Standards and that a
if this Is a repair,Jill out known well constructlon information and explain the nature of the._ copy of this record has been provided to the well owner.
mak under 1011.reinarkr section or on the back of Ibis form 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closedtoop'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 naeiled.•Ihdlt;ate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(7erent(example-3 200'and 2(g100') construction to the following:
10.Static water level below top of casing: a (ft.) Division of Mall Water
ServRlca Crces,Ienter,Rormataleigh,Information
N Processing
oc ssing nit,
((water level is above casing,use"+"
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11.Borehole diameter: A (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�o.�•y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(I.o,auger,rotary,cable,direct push,ato.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
rr// r r
13a.Yield(gpm) Method of test: it/Y.' 24c.For Water Supniv
'1'"d &Inlection Wells: in addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: e OY14G Amount; Z c $ completion of well construction to the county health department of the county
/ where constructed.
Form OW-1 North Carolina Department of Environmental Quality•Division of Water Resources
Revised 2.22.2016