GW1--01135_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:.
1.Wel4AY
ntractor Infotio - , ..
Name • FROM TO DESCRIPTION
Well Contra
for
NC W I Contractor Certlficaatlor Number aj.5.<„0 111} * a;$XNG!(jol';nits(ii± p'¢iLti4tflts)t01ij!)1n 7IDi i`aka'llb8blk)%=
�( S 1�(/lit/ - � �p i �L-r 1FROM ft, TO DIAMETER
ft. [DIAMETER
In. 5U 1�.2-, M TERIAL
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2. yNamb q/ /a ' '60;g)NNN) tyy�il911V4.',Q1M alifffdtllti ns lbitotietlBl`v:41 •4•:f :••:.•::'•::":• '
2.Well Construction Permit#: G ! 1 FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,,State,Variance,etc.) ft. , . ft. In.
3.Well Use(check.well use): . ft; ft. In.
Water Supply Well: . `FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural . DMunicipal/Publio . ft, ft, 1 , In. - .
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) - tL ft. I ; In.
Industrial/Commercial DResldentialWaterSupply(shared)= i18gbli(l;ltc<r,;;..,rv;:r;w.ir(.;:;?;:iii:Ca ;{;:';��(=``v .2`}.ib.;.:
•Irrigation . - FROM • TO �ryI MATERIAL r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 02- ft. i' n.ie,uu/e pDp>^ria"dt 13 .11 ACS,S
Monitoring. . DRecovery. _ _ . ' ft."____ ft,
Injection Well: rt. 'ft.
• Aquifer Recharge. 0Groundwater Remediation
3514107•GYA'.BEiPM 401glilRilailblrki!. ?i?'r:,.:,;::.4 :;':.;-:-j.s:•- ".:..•••.
Aquifer Storage and Recover) ' DSalinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ,, •.'.• DStormwater Drainage ,; • - ft. ft.
Bxperimentel Technology .,, OSubsidenae Control ft. ft y
' Geothermal(Closed Loop) ' Tracer r .
;;Z•pyll,�G"(!)61�ITp��(att'�Q'�a31i1[Niid'all$ke`)i't6il'f:ii6:okfaet�:;;��•:.:`:•. . .. :.•:.� •
FROM TO - 1 DESCRIPTION(color,hardness,sotVrock(y e,groin pre,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) p �. �Q✓�l t x
/9 ft' J/4 ft. 'jl4- & ety, I
4.Date Well(s)Completed:;-71 / oZ 4 Well ID# ' J 1511, 8‘7,_.6- ft, '• 'pi yeuu��
. n, ft,5a.)Well�l Location;_/' I/ f� • .
vVYYC, V -k `� Y ft. ft.
Y ft. ft..;• t f.rLII...i!Vf.G..4i
Facility/Ownor,Nama Facility WO 3_ •
l I,2.3 1{✓•l°y' R l , l)a ft. ft. k tj C 2024
Physical Address,City,and Zip " 71i€ VE 5 ' .ft., ft.
6-1 4 l�(�l /,'`- y2oItFi o;t j '':Yr:>=_. °"••' .A4 is,1`\ _;..t..),r.:.1:.;LW,
County
Parcel identification No.(PIN) . DWQMt�C
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees; . -
(If well field,one let/long Is sufficient) 22.Certification: ' ,
, �a9.6
9lbgI g1 i
N � w A4. al-g-� - .
; l
6,Is(are)the well(a) Permanents'dr Temporary Signature ofCertified ell Co Date
Sy signing this form,I hereby!ceriffy that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: I Yes or 119No .with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
_Ifthis is a repair.Jill out know:wall copstructlon heformation and explain the nature of the copy of this record has been provided to the well owner.
repair under q21 reinaks section iron the back of this jowl' 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 OW-1 is needed. Ihdioate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: - _ SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: ,• -� ' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffd(fJerent(example-3@200'anndd 2123/00) construction to the following:'
10.Static water level below top of casing: v p (ft.) Division of Water Resources,Information Processing Unit,
(fwater level is above casing,use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
•
11.Borehole diameter: C) in.) 24b.For infection Wells:, In addition to sending the form to the address in 24a
above,also submit one copyiof this form within 30 days of completion of well
• 12.Well construction method: 0 a'Y')/ , construction to the following: -
(I.o.auger,rotary,cable,direot push,etc.) • i i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY('yWELLS ONLY: t 1636 Mall Service Center,Raleigh,NC 27699.I636
13a.Yleld(gum) -/ Method of test: a-/ Y 24c.For Water Supply&Infection Wells: In addition to sending the form to
PP
l the address(es) above, also submit one copy of this form within 30 days of
13b,Disinfection type: U'U p Y'/fl Amount: C completion of well construction to the county health department of the county
where constructed.
, I Revised 2.22.2016
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources