GW1--01146_Well Construction - GW1_20240219

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. WELL CONSTRUCTION RECORD(OW-1) • For Internal Use Only: ,•
1.Well Contractor Information;6tkr T Hams Pa d _ FROM TO I DESCRIPTION
Well Contractor or Neme ft. I ft
45 y5 ft. I rL• •
NC Well Cent actor Certification Number /I . -,'o'd"1,�1{d we i'(i:f((„"11 I'�.t:v.F.!` -;,:n. •u)"UrigvW;jtY,i 1 Jilt).1.� 'r;:: :'
S Wel� col
d , FROM TO I DIAMETER THICRNES: Turk,
(.Gv.n` G rt. 0;:ft. .17.,5 in. S VA 7.1 rVC
Company Nebo •
�+ /1, -Ir Yf ir'1?'�E VF-i f.;.•a'`hitaW F`NN.a";. `'e';t 11Y ,M`,";,.2 t rt..tt!Mti,.I„,2.Well Construction Permit titc7 W 23 -0 1 g) FROM TO . ' DIAMETER THICKNESS MATERIAL
ft. i, ft, tn.
List all applicable well construction permits(Le,UIC,County,State,.Variance,etc.) 1 fa.3.Well Use(check well use): ;' o, t.�3:ir a • + r{ i:;rr,' �; U.,'..Itv;clt;t
'Water Supply Wells • FROM TO ' ' DIAMETER SLOT SIZE THICKNESS MATERL
Agrioultural ©Munloipal/Publio ft. ft. In.
Geothermal(Heating/Cooling Supply) isResidential Water Supply(single) ft, h.i . In.
Induetrial/Commeroial DRosidential Water Supply(shared) . „f c-.o VI, 9ry1,i',• i."4.;!l;r.,;iiVg..ti.6^ 4,;4 ::',',:, '.i) S h.'(*`£,'.....C.isti
Irrigation FROM TO I I MATERIAL EMPLACEMENT METHOD&AM(
Non-Water Supply Well; •
0 ft. AO eft. 1 t„,,.,Or'. 1 V gc4C�S- 06)I)Monitoring • 0 Recovery to ft. 0
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- - •Injection Well: - - - - - - fA .. ft. -
Aquifer Recharge Qt3roundwater Remedlation : t' /e)")\:;: e fy. a rl ;is;t I IY t(;yI ,$501!'. :a•:/rt:+C, 1rd.tslst °{,Y 061
Aquifer Storage and'Reoover' ' . DSalinity Barrier . PROM TO ft. MATERIAL
EMPLACEMENT METHOD
Aquifer Test •.-N. \ `,• OStormwater Drainage . .
ft.•
Experimental Teohnolo •,"�' 0Subsidonoo Control ft. ft. •
P oti) ',,.,. 'iiir/Pl•'.1gJ,-'q c . .0,ATM.1.f 1' •.0•r' ut Au,[:'t/61.1x.,?4i.rk,30.,;
` Tracer
Geothermal(Closed I:OOp) �' © FROM To. I DEBCRIP'rHON(color,hordneu,eolUrock typo,grain WIN,
Geothermal(Heating/Coolin;Return) f Othor(explain under#21 Remarks) .0 c. 06. ,ft. CI ay
4.Date w,ell(e).Completed:' l Id•�.4 well ID# G 1 It. W 8!ft' G rt.tvt •k.
k ft. I ',ft.
5a,Well Location; ,
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ArAvid -1310on1�;t;)d h, 'rt. --�
Facility/Owner Name FaclUty IAN(if applicable) r '�^9 I' "
tt. ft. sy'1, C"I
3O 6 V r I�Z�J( rd s Way �' 1 R. I rt. FEY 9 "1 :
Physloal Address,City,laud Zip I ; �a z - •2.,; ' ;i::•.,•• ?;,.'. ;;i
pi vilvt.4or ci • ,
County Parcel Identification Ilk,(PWZ- 1 ; r `u41� (%r.s
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees;• •
22.Certification:
. Orwell field,one lat/long le aufiblent)
• 35;W5ic36 N . 87.16L150 • w ��I 1t 1_ .
8lgaetiue of Certlfled I Contractor 4 Date
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6.•
Is(are)the weU(e) Perwaaen 01 Temporary -
8y signing this jorm,l hereby oert(ly that the well(s)was(were)constructed in acc,
7.Is this a repair to an existing well: Q'ies or'�No . ' with 15,1 NCAC 02C.0100 or 1SA NCAC 020.0200 Well Construction Standards an
• copy.oflhls record has been provided to the well owner.
_.- {�ttib la a reparr,f111 out known well-construction information and expfarn the nature of The: -
' repair under Nt1 remarks section or on the back of thisform. • 23.Site diagram or additional well details;
You may use the bank of this page to provide additional well site details,
8.For Geoprobe/DPT or Closed-J.00n, ebthermal Wells having the same construction details. You may also attach additional pages If necessary,
construction,only I OW-1 is needed.'In costa TOTAL of wells �� xT�INSTRUCTIONS
drilled:
9.Total well depth below lend surface: S go 5 (ff.) 24a.Yor All Willi: Submit this form within 30 days of completion I
• For multiple.welis list all depths.if garotte(example-3@200'and 2®100') construction to the following:
I
10.Static water level below top of casing: L.) (ft,) Dtvieloa of Water Resources,Information Processing Unit,
If water level is above basing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
-11.Borehole dfame%ert 6 (in.) 24b,For!Weeder:Wells: In addition to sending the form to•the address
+ above,also.submit one copy of this form within 30 days of completion
12.Well construction method: I LI 1'Ci.ry construction to tir following:
(i.e.auger,rotary,cable,direct push,eta,) Division of Water Resources,Underground Injection Control Progr
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
Method of tests 24c.FQj'Water Snnnly&IDlectlon We11e: In addition to sending the
13a.Yield(gpm) 7 r r the address(es) above, also submit one copy of this form within 30 r
�(1ori Ile, Amount: V oomplellon of wellf construction to the county health department of the
13b.Disinfection types• where constructed.
Revised 2.
Form OW-I •North Carolina Department of Environmental Quality-Division of Water Romeo .