GW1--01536_Well Construction - GW1_20240312

. PrinfForm = .
• WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only: --- :• - ..
I:Well Contractor Information - • • . '. . -
.Gary"Thompson- .- . • ••.14.WATER ZONES.-.:.., . :__--:_ �. ._, ..,_ ___ . .. :
FROM .' TO . DRSClIFrION . " --
Well CainmototNag 10/,-D'- .`7.IC /Z"•'.Crnt.'�1,or' S7:GOiv^ .
441.8=A. • • - ' :S�a•fr. 5'4 t.F" .n' . Frrc i+'." .'rj'-'(.4;64.1. . . .
NC Well Contiactor CettifcatiotiNninber . • . . •15.OUTER CASING(for.enitlased Wells)'OR LINER(if Up bte) " - - •- - .•
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• • "FROM .'TO.• ._ _DIAMETER` • '. 'TIRC1O ESS MATERIAL - -
Aqua Drill,:Inc • e • ft. •It. •'•, ,: • to :1. . C�P �p 1. . , .
Cokapany Naito.• - -- :U`k'"VP:/ ..
L . 16.INNER CASING.OR TUBING(goo:OvinedoleddoopF • _
2:Well Construction PelTalt# :T��/i U iS t:3t3 —T . - FROM " .TO DIAMETER •THICKNESS. • MATWL • • :. .
• List all appllcabl!.wett constntellon pe mlts(Le:.UiC,Cotmcv;State,.Va lane.etc) •. - - 'ft .
•. : 3:.WellUse.(checkwelluse):. . - tf• •• . • . .. : . ' '. •
• ft' le.'
.' "17.
...• Water Supply Well: FROM' TO - DIAMETER SLOT SIZE- THICKNESS MATERIAL - -
cultural- . • . " 3MunicipallPubhc: • : re.' . ft.. In. •
' • Geothetmat(HeatingfCooling Supp1Y) -(3Residential'Water Supply(single)• .. ' - ' - ft.' .In. , • '.
dusttiaYColt�tercial ' QAesidential Water Supply.(shared): le.GROu I =
hriJtation- FROM . . .-TO • • -MATERIAL- EMFI,ACEMENT METHOD&'AMOUNT .
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. •I Non--Water Supply Well: . . . - •. . : ):Li. .5.1' •IL_: .3 N. • p uvv� Q. •
Monitoring ORecovely. R. R,'
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. Injection Well:: • _ ft.: : . f.: : .
reiR�'�. . . O(hvundwaterRemediation . . • • _
19.SAND/GRAVEL PACK Ofsonfteatite)-.
mulct
L$WingeandRCcovcty ogalinity.Barrler FROM TO. MATERIAL • EMPG10E1wrMrMEmoD' •
er Teat• . �StonnwaterDrainage•
metitalTechnolog,' . ..OSubsidence:Control: -ft.": • • ft.
[+� LOG(attach additional stunts If setenaty) ' -
elmal(C(osed�Loop)_ F,,,rTrztc�r 20:DRQ.LIlYG - •-
FROM. • ' -TO . DESCRIPTION(r1sr.tuNnen,iallkoektbp:,[��. ) - .
ermal(Hauxtinp/CoolingRctam): �a�tite[(etrpleinundusr#21 Remarks)' lt. :
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• ti •
:4.Date wel(s),Completed: Z-1e.� t::Wei maArr.( 1 hL.4 :10 -•R ."Gr ^- i e: • .
5a:Wellleeatloe: • - t " •.:„...._ . ._l1
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Facility/Owner.Nome•-. •. , . -Facility fill(If applicable)'. "D'- ft' i , .MAR G 2024
• . Pe;Nii'pu'g�:1a"-O+: :1 y‘:o •L;pk�:: . • . • ft:' . •
• . FhyaicelAddriss,Ctty,sndZip. '' ft.. it.. ar^.,._ s,rz i{.
- 1„if'lil/l M^L�"d 11 1 ...•�:l+'...n.Jfi.
:21.REMARKS ' •.. . . _• , •DWC}i's x.-
PaiccihleidiHcatlon No.(PIN):
• 5b.Latitude:and longitude in degrea/minutedseeonde or.deeimal degrees : + . .. '
: giwellgeld,.ate tat/long isaudicient)-. • :22.CerdHgtlon:- .
r rl
. '34 ''i yi;',"ai . •. .N.. .y'i'. a ' 61f.,ill. . - w.' . ••r
• 6.blare)the well(s) Permanent- or:OTemporary. - • Sigpuoic of erdfled;W.a Coutactod, -Date•
� By signing thLIlorna,I hereby c"ah;fy ilrat.the mills)was'(were)constructed ln.accordance.
7.•le.thli a repaIr tole existing well: '.®Yes•' or IQ"0 - • . •with"RSA NCf1CO2C.0I00.or RSA NCAC 02C.0200.Well Conatrucilon Standards and that a. - .
• .yeds.ls a repair fll outidroum well anottreation trdonnatfon and captain the nature oldie' espyofthis reirondhas bear provided to the well orwter.
- repairundal.021 remarks section oron the baelrgft hfonn.• 29:Site diagram or additional Well debris
. -g.For Geoprobe/DPT or Closed.Loop•Geothermttl WeW having the same - :You may use the back of-this page.to provide additional well site details or-well - .
1 OW 1:is needed.'indicate TOTALNUMBER of wells . . '.construction details. You may also.-attach additional pages ifnecessary
:cotuvhactioa,,oaily - .
dulled . •- • : .- • punkur'AL ttitrRUCTIo s . .
- •• •9 Totaliwell depth below boil surface::- • . 0.S. . : : •(ft.) 24a:pot...Ng:wan. Sabmit:thi•a fonu within 30 days of completion.of:well: "
F• orinaltlple wells Ustdlldeptlir(fdl�erent(eamapie-3Q?00'and 2®l00): :constnrctiantothe following:. 1 •
10.Static waterlevel below top of cash: ' lg.). Division ofWater Information Processing.Uriit,.
!floater level above casing,use'+^ 1617 Mail Service Center,Ralelgh,NC 276994617
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11:Borehole diameter. A• ' • '(Inc) . 24b:•ForinleeNaa Wells:'.In addition to sending the form to the address in 24a'.
:12:Well contraction method: • )'�'?o' - :p1.v -. _ . - of-completion- of
above;also submit one copy of 'form"within dayswell•
constenctlon to:tite follovuiag;
. (te.auger,rotary.cable,'direct push,eta.) • .. • • .
- , - ' -Division of Water Resonrces,Underground Injection Control Program,•
. FOR WATER SUPPLY WELLSONLY; . •163i Mall;Seivke�Center,Raleigh,NC 27699.1636 . • •
• 'I
130.Yield"(gpm) t 0 Method.of tom. �.bl-c.1•It I.•;►''.a`• • 24c.For Water Sunolv'&Inleetli n Weil': .In a'dditiba to sending the form to-
the:addtess(ce) above, also:submit one"copy'of this,form within 30 days of
• • 13b.Disinfection typi:•'tom t,T+ O . Amount:• -3•�-'AL . . . • completion:of well consttaction1 to the county health deft of the con*'
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-.where constructed: . . .•
. Form OW I North Carolina DepaRment ofEpviioeritentai Quality-Division of Wetor Rcseumce'.. Raviscd 2-22-2016.