GW1--01470_Well Construction - GW1_20240301

WELL UUNI.1•KUC11UIV KUt.•UlU/tti 'V-11 For Internal Use only: i
1.Well Contractor Information:
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Well Contractor Name • FROM TO DESCRIPTION
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NC Well Contractor Certification Number 1
(j ///��� •A lkaiIYP];lt t Stka(f igiijilit gas l avells`):iJ,R.I,tUitca ap_Citable)` V:i..,�>_•
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a r I FRAM i T(1 I „,,;RTFR j THICKNRSS 4 MATERIAL
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2.Well Construction Permit#: G+.^a y- ®®� 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. , j in,
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Water,SD 1 Well: i-17. +l' ,a.e r^h;.�fT nt^r.tr'`t...X_fi..aki4t f.:.,•..�4i..f4t - 4�W;S s,t^•,li,,A I- it;,I
`r 111!.y _` FROM . TO DIAMETER SLOT RIM 1 THICKNESS MATERIAL.
°Agricultural Dlyfunicipal/Public, ft. , ft:.. 'in:'
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Dlrrigation °Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1-0 ft. iv-Ch j)f�2J rq VI*
°Monitoring °Recovery ft. ft. LI
Injection Well:
°Aquifer Recharge °Groundwater Remediation I f t. `
QA offer Stores a and RecoveryC1Salini .Barrier t.k9::SANDIGilAVE CACIt�(If applieab'1e).- .:e,' �* .$.zit ;, •
q g ty • FROM TO MATERIAL, :EMPLACEMENT METHOD
❑Geothermal(Closed Loop) °Tracer 17t;1Dt i+l+[?#;27i(n(aria'elOdiiitiiiiii s'tieeisi6te¢esaa V O i V• to f!g
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,salvrock type,grain size,eta)
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4.Date Well(s)Completed:P-1 J' J 23 Well ID#1 lb V Gal 76 fL - B go n' �r ales fie, V D�t ;
Sa.Well7[.ocatlan:
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Facility/Owner Name Facility and(if anniirable) • '1;' D• i- .•
((4 9qun• _ In b.-ddie,s ft. ft.
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Physic Address,City,and Zip ft. tt
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County Parcel'identification No.(PIN)
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Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r-.
(if well field;one lat/long is sufficient) , 22.Certification: 1
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6.Is(are)the well(s): °Permanent or °Temporary Sigaofrttfied Well Contractor Date
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or gii<o 15,1 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain*the nature of the of this record has been provided to the well owner.
repair under 1/2I remarks section or on the back of this fonts ' i
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,pagelto provide additional will construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
d.l""` 24.SUBMITTAL INSTRUCTIONS • -
9.Total well depth below land surface: # U Li (ft.) 1 I A
For multiple wells list all depths if different(example.3®200'and 2©100� Submit this GW 1 within 30 days of well completion per the following:
0 24a. For All Well : Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) 's Information Pro"asing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
ILBorehole diameter & (In.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(I(JC)
Program,1636 MSC,Raleigh,NC,27699-1636
12.Wen vnn.etrnetlon method: - .,�. 'fA,. C.,.-u7o*.,rRn,,,<,Iv'anll lb:.n _T nun r ntlforinai P.tnrn Wnllsc(gpytit the •
to •..v .a►e s.a/•
(Le.auger,rotary,cable,direct push,etc.) ul t r l v l rami / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: / f 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
'3013a.Yield(gpm) � - Method of test: ' 12--W Permit Program,1611 MSC,Raleigh',NC 27699-1611
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13b.Disinfection type: I/ Amount: f.z lb ry• .
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised-6-6-2018