GW1--01134_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:I
1.Well ontracctor`Info�rmatio j
Well
re / i4 ii-it - I'A`r�}i!t 1�'yGOM1NL`3v%.'• .�i?+gz' ?;=>'.':`
Well Contractor Name = FROM TO ;DESCRIPTION
ft. ft.
.1�, �24
A: ft, rt. 1
NC Wcll Contractor Certiflcatl n Number •
• _:O:SiA:U01 MP1 41010%(fo">'Tinuijkitiet'ROIRsM ti IN}Iii(l taiIMi
lci(81h).:••• . .. • . .
ea-01 ���' I ' k PW14/3
FROM TO 'DIAMETER THICKNESS• ATERIAL
�/t7 a.) LL 1 ft, J.3.1 ft. )a.51n. s0 R 2.) ►c
Welly Name 1 '27 4 ' ?,1'd foolo It('I U1G;QIs4r($)BBINti;availdiala)}Ilq➢eflt:l`kYi)'rC.'r'_z,..:..::•::, := •• - .
2. Construction Permit#: !✓ FROM. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UiC,County,State,Variance.etc.) ft. ft. ' In, .
3.Well Use(check well use): it, ft, 1 In,
i1,111S*DRE N'.:VA'P*,.iisi.t.;:::2• c; j; a ,.: .•...`'c:r.:••. ..;:•.::::,:. ;.•. ..,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. 1 in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) H. ft. , In,
Industrial/Commercial DResidentlal Water Supply(shared) ;ry1.8Jb• r,m*..41;=r ;tip: *.f ;i itz:.A;;,`- 0: %0.4..;!'
•Irrigation FROM TO 'MATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: p ft. j1 ft. )od (j-e pax „r/3 �Jety
Monitoring • QRecovery • ft. ft, / u
Injection Well: • ft •
, ft, I
. ;Aquifer Recharge ME Groundwater Remediation k d ,. , +(if . r•
A7i/ji ND/.0)Z1V•EL"ilt..' 1 fkitlAtiC81ifel .+n"`:::. :::;•,.:.:'% si1-•;•:•..:•:.•.•
Aquifer Storage and Recovery' ' .. Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD•.
Aquifer Test `.•}, DStormwater Drainage ft. ft,
Experimental Technology QSubsldence Control ft. ft.
�' 12 0.01I1i1,Ci ,eftir1 41101.Hoffelidtiiikeifffiili ifi. ):;;'.:::.;`'s••. ... • . .
Geothermal(Closed Loop) `4,>. Tracer < 1,D '(
FROM TO 1 DESCRIPTION(color,hardnesr,,ol0reek type,groin ell,etc.)
Geothermal(Heating/Cooling Return) r�11 Other(explain under#21 Remarks) L� ft, 13 grfttt. 1 Y!r G 1 a� 1 Ydt tl eri 1+'t 1IC
4.Date Well(s)Completed: �•����7 Well ID# • ,4Q ft. , n,7 ' 1 r 4Cni-te
f4 ft. IV
W II Location: F
r It, ft.
�Illl i-1��o%f)'7GJa. � EYU'LC!— ;6 q y
Facility/Owner Nam...., Facility IDN(If applicable) -1 ft. ft. �,t i \A e J f ,•p • •
1113 �b�yi's i P � ��y' It, FED 1 �C 2024 3.
Physical Address,City,and Zip ` v e j ft. ft.
�:• :i, um
rti5Ot4
County Parcel Identification No.(PiN) f�ifi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; •
(if well field,one lat/long Is sufficient) 22.Certification: •
`P • ,,Z- 1.2 -,Z 2)
6.Is(are)the well(s)r3 Permanents drTemporary
Signature of Certified Well Contractor Dale
By stgriing this form.I hereby car*that the walks)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or lffiNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
_ _ .__ __ . ((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 Nth reinaikr section or an the tiack ojtldsja nt' 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 I OW-1 is needed..Ihdlcate TOTAL NUMBER of wells
construction details. You may,also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
' 9.Total well depth below land surface: 305- (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifd((ferent(example-3®200'and 1®100') construction to the following:
10.Static water level below top of casing: Q6 (ft.) Division of Water Resources,Information Processing Unit,
((water level is above casing,use•'+' 1617 Mall Service Center,Raleigh,NC 27699.1617
•
11.Borehole diameter: l At (in.) 24b.For Infection Welly: In addition to sending the form to the address in 24a
•4- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ` �Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699.1636
ff��,, 1 I
13a.Yield(gpm) d,t/ Method of test: �-) r 24c.For Water Supply&'Infection Wells: In addition to sending the form to
c• q the address(es) above, also submit one copy of this form within 30 days of
13b,Disinfection type:` ' �f"I 1) Amount: o� C / 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