GW1--01151_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor'yo at on:
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FROM TO DESCRIPTION
Well Contractor Marne •
r ft. ft.J ft, ft, 1
NC We hContreotor Certification Numb •
ler �/ at,S b JtYlp(t'•,;K$INGI(jo>~i#iut(I hbedlli Il`6);0 y1 1NE W! s�i'lI&btb)I•:'•
GLn 1 °iG �l'( }✓L t�i. /�l�� FROM ft. 3 ' ff. 6, 1 "' S 1� I METER THICKNESS. MP yG
ATERIAL
Company Nama <�1�;s1NN14iI�CYiti811sf4�(2�•4fi� `Itdti�li,+�+f(1la�in Ibl6A o.4�)^•�. ..
511 - a/A ,:.:T..::.:: .
2,Well Construction Permit#: FROM. TO DIAMETER THICKNESS MATERIAL
ft. ft, In,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) -
ft, ft. . In.
3.Well Use(check well use): -
(rsL7t:sOltE N^-.;4Sin:'•'�i S: v:::a.�+f/ ;i4;%1_Z:Z:s`R%�n`ti.1,: .:•:::,:
Water Supply Well: .FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMuniclpal/Public ft, ft, In.
Geothermal(Heating/Cooling Supply) 14 Residential Water Supply(single) It. rt. I In. .
Industrial/Commercial DReskiential Water Supply(shared) kyll)i?bgo!is;,t< , c ys .`.;ti:;,ttu ;= ;i°,= ;1' -:4,:. 'P.L •fi tt".,3y.:A:;k-'t•n!.:,- ,...
•;Irrigation FROM TO ;MATERIAL {- EMPLACEMEN METHOD&AMOUNT
Non-Water Supply Well: . d tt• D it' b enfini t e L e U' — 1,2. �u.Q.5
Monitoring_ - _ -:._ DRecovery . rt. It, p ��//
Injection Well: It, ft,
Aquifer Recharge DGroundwater Remediation 0190"4:1 .10#60 141KO ZIatiiilleabtiV,t•Nii• ::.::.,:;:„ i :•:., •
Aquifer Storage and Recovery' ' Di Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • \, 0Stormwater Drainage ft. ft,
Experimental Technology '.. DSubsidenoe Control • ft. ft.
Geothermal(Closed Loop) Tracer :;30;s11 t:IN 'IT t):G<(aftAoJi?.kildltreitnttih'eti'te'fftde'c eei6:;; ' . :.•.
FROM TO DESCRIPTION(color,hardnerr,roNrock type,grain size,etc.)
Geothermal(Heating/CoolinggqReturn) ('Other(explain under#21 Remarks) v ft. R. y�- 1 A
4.Date Well(s)complete di 4-'-4; Well ID# .3 8 ft' 40 Jt"tt' marl
�• ft. ft,5a,Well Location:
Gar i l'�n- t)1t �w:.. , r g 3
. Facility/Owner Name Facility 1D#(If applicable) ft. ft. ' n ! L,,, ' �� ;t :+ •
/� // 1�,up:it a 1Kn C. l ,�, , It, ft. E ,
Physical Addras it A y,and Z
u rh-e! brid 3 tE►fAof-` ;%?: • . a 'ztr ;:;2:fa .;=i: - .:? ---- �..::.
Parcel Identification No.(PIN) G1r)Q v O`"
County .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; •
(If well field,one let/long is sufficient) 22.Certifl ation:
3,�", DIM-0 N -e1, q o 9 W •rd/� ' ' -
6.Is(are)the well(s) Permanent drTemporary Signature of Certified Well Contractor
By signing this form.I hereby cerl(h that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1lki Yes or MNo with IJA NCAC 02C.0100 or IJA NC/IC 02C.0200 Well Constracllon Standards and that a
•If t is Is a repair,fill out known well copstructlon t t(ormation and explain the nature Oho copy_of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed-Lobp•.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-I Is needed..Ihdioate 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: (/� (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(/'d(Q'erent(example=3®200'and 2®1007 construction to the following:
10.Static water level below top of casing: 1 O d (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: LP/4 (In•) 24b.For Injection Well In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y t I V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Retsources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 3 Method of test: Gar` 24c.For Water Supply&Inlection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ��I OV(n.� Amount: r G lit-/9.S 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