GW1--01759_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:;
1.Well Contractor Informatiop
(•7 A,Y'V'.- �j "t - Yaa;:vv ibls'>� rl :::..,z,, ,. �:,..> ,•<:'a '::~ . .
V • FROM TO DESCRIPTION
Well Contractor Nem[a Q ft. ft.
NC Well C ntraotor Certification N}mbar 43f5 O m OIV `IC;,t(t`o atiitlij .'dd, 0 1NOR((ff b'kpititilia%• . .. .
Well
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�e C, PROM TO DIAMETER THiCKNESS•r I MApTERIAL
J � ` R. l6 9 it, ,�oc'5—tn, j DA c2. I vG
Company Name ;I�s II°fYAlS1N4QTt i3lli{(fdF{ItiiiielbloeilRtoll)v :tt:: .. ... .
2.Well Construction Permit#: I rFROM TO DIAMETER THICKNESS ~ MMATERiAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)
` f0 ft. in, •
ft, ft, I In,
3.Well Use(check well use):
!li[itg-OltF Ii.!::4 ii.%4':y;.?';iai.-: ;•44- d,(.;S:2;.L:S.-;.;/../;;•:•y;•::.:•. {:., `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • OMunicipal/Public ft. ft, In.
Geothermal(Heating/Cooling Supply) EResidontlal Water Supply(single) ft, ft. I • In,
Residential Water Supply(shared) r fi;i<, s cs� ".i�'^;a"'giika '�': •::r�y t- :cc, :.;s; ::.
..;lndustriaVCommercial � :y18i4GfRpfi7 ,.,-::,.;.:.._ :,�1,,, t�r�a�: �ia�, _,•.,.:.�^;•_�:�'`i:: ... .•:..:'saY;�:,;�..'..
FROM TO MATERTAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. .a O ft. h en-kit;f- 15 b is o to"e—JJ
Monitoring . - DRecovery"" ., ft. -- ft,
Injection Well: . ft. ft.
Aquifer Recharge 0Groundwater Remediation ,$A':SA 11'?.oti!Av11.)3qb'+(ifs`itiilooaHlw,:;,,li••:::::.;::?:i•',•::.:-i.s:�.,...,:•• .
Aquifer Storage and Recovery ' 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • 0...:, EliStormwater Drainage ft. ft,
Experimental Teohnology ., OSubsldence Control . ft. ft. i
:20.3111 fslt>7 %t 04i(afYao 93titl'tloiSaifefie tifffidaulbea:�):.`::: :;':;_• .•..•:.
Geothermal(Closed Loop) Tracer �'
'FROM TO DESCRIPTION(coto�,hardness,soli/rock type,grain size,ale.)
Geothermal(Heating/Cooling Return() ,IOther(explain under#21 Remarks) O ft. i D ft. y,i C 11
4.Date Well(s)Completedi . —I '24"Well ID# . 1 )(� ft, l� 51t, :4)n2-� i+ j .
Sa,Well Location; �.
•
1 ft.• ft.
/)�r 5osebee •
R. ft. MAt( � 0 2G24
Faalllty/gWnar Name Facility ID#(if applicable)
D� !� 5.J._ ,( ()
v' ft. ft, i
Inf:rt. ft. :�'l'""
Physical A dress,City and Ziiip fy nn�f(�.jj�(�( D�"rQI O(
• County Parcel Identification No.(PiN) •
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; • i
(if well field,one IaVlong Is suffiolent) 22.Certification:
, ..5"�.5 y-g 3 N — 1. OZ7 3 4 b W '��422 ; �!1.� f'
Signature ofCertified Well Contractor Date
6.Is(are)the well(s) Permanent 'drTemporary -
9y signing this form,I hereby eel.*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or eNo: - . with•l54 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction htlormatiot and explain the nature of the copy of this record has been provided to the well owner,
repair under#21 reinai•ks section ar on the back of this form. 23.Site diagram or additional well detallsr . •
8.For Geoprobe/DPT or Closed-Lobe Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
• construction details. You may also attach additional pages if necessary.
construction,only 1 OW-I is needed..Ihdloate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-4—__6— (ft.) 24a, For•All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(/d(perent(example-3®200'and 2®100) construction to the following:
10.Static water level below top of casing: gs() (ft.) Division of Water Resources,Information Processing Unit,
ljwa�er level fs above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
•
11.Borehole diameter: '/ (in.) 24b.For Infection Weill: 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: V 0 fia_YI. construction to the following:,
(t.e.auger,rotary,cable,direct push,oto.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699.1636
I
13a,Yield(gpm) ea.. Method of test; a—,r 24c.For Water SuDDiv&Injection 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: u\(� i Amount: 7--. /�L�/Ps completion of well construction to the county health department of the county
f where constructed. 1
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22.2016