GW1--02071_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well 5rtractor Inform Lion: j
ett- •
ilmov .it!tLQI!fEtt Rw-ire..`r :'
FROM TO DESCRIPTION
Well Contractor Name � ft. ft.1 I
4 6-1K A
NCW II Contractor CertificationNumber $Fi9t) ?Olt *t yf( ((�Pi`ul efd4 4Ill)Y.'It�iIILVti(i((i?e$ li'cglil
•
wed) p 6 T,c_
FROM TO DIAMETER THICKNESS MATERIAL
�7 ``' l�i/l 1 u-��• ft. ft, )�51n. p 27 g z) I` Y
Company Name/ /�'I 1�iNNERt i
1VG=OR . INO eoth6Ft teiilb eMlkocO=``:t=::.7- •' .
! l iJ6 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / d- n, ft. In.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) In.
ft. It. •
3.Well Use(check well use): -;;> r I'::;::1. :.,:.,y•-.::.r,;''' `:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural
OMunicipal/Public It. It. 1 In.
Geothermal(Heating/Cooling Supply) :7-?'Residential Water Supply(single) ft. ft. I in.
Industrial/Commercial DResidential Water Supply(shared) fgt,dR r =,,< t=.-:: i,;<p 7 =' s
Non-Water Supply Well:
FROM TO MATERIAL L �EMPLACEMENTMEETHOD&AMOUNT
Irrigation - it. it. .ben oil I& b c _ ``3,-,�i5
—_ --- — go ` - -
Lr•F
.�Monitoring
Recovery ft. ft,
Injection Well: ft. ft.
Aquifer Recharge ' , `I Groundwater Remediation : r:;• %i:.;": •�_{:' -�`:"'•
_1Ai$M4P/GI AVJF Ii �b (IfaAd`ifilbafiliil::
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
l' i
Aquifer Test ' ;,',
Stormwater Drainage ft. ft.
Experimental Technology \ ,.:•, Q^,Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer •Y4,,Y!>Ylfi lIgek,;ti:Ot(i;tid3e1ilpililttlhirti:rihee''editt=rie sar8C; :-<::g= ::
FROM TO/ DEI7CRIPT ON(cItr,hardness,sol0rock type,swain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) (J ft• Itt, ((�JJj�t'
1
4.Date Well(s)CotiiQleted:, '� -� Well ID#
J /ate IL 5 fL 1 ra-n)�e-
1 5a.Well Locatqn: • It• tL E .4' F % .'
/ Jlt ae 1 PA i d -e .ft. ..�Lt` 4''''i .'
ft. ft. A ;-" 9021
Facility/Owner Name Facility ID#(if applies le) D
• Dsrf /�a.N rah S�r/ S ft. it. t(tt�:i �;':, ^,;,:.....Win:
Physical dress,Cit ,and-- :Nr•.. `'�f::. . .. 'gar}�.i ,:-:�r :':;'.,,...`, ... -:-
County Parcel Identification No.(PIN) --
Caunty
5b.Latitude and longitude In degrees/minutes/seconds or decimal degreesi •
22.Certification:
(if well field,one lat/long is sufficient)
.), 0 S.49 N `-. V' ) ' 7.1 I W g l �g-'Zi<
Signature��ofCertified Well Contractor a
6,Is(are)the well(s) Permanent dr Temporary
- - _ By signing this jam.I hereby cer!{/y that the weil(s)was(were)constructed is accordance
7.Is this a repair to an existing well: iIiI Yes or giNo • with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this Is a repair,Jill out known well copstructlon information and explain the nature of the
copy of this record has been provided to the well owner.
repair under#11 reinarkssectlon or o0 the back of this form. 23.Site diagram or additional well details:
•
You may use the back of this page to provide additional well site details or well
8. •
For Geoprobe/DPT only 1 OW-I is n ed ed. E dlcat Geothermal NUMBERs having the sameconstruction details. You may also attach additional pages if necessary.
construction,only 1 is needed. Ihdlcete TOTAL of wells SUBMITTAL INSTRUCTIONS
drilled:
i g/J' (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: �
For multiple wells list all depths(fdffereet(example-3®200'and 2/®100') construction to the following:
'7
10.Static water level below top of casing: ` G (ft.) Division of Water Resources,Information Processing Unit,
((water level!s above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.Borehole diameter: Go / (in.) 24b.For Infection Wells: �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: 16 / ".--"• construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
t
Method of test: A-1 .r 24c.For Water Supply&
& ,Infection Wells: In addition to sending the form to
13a,Yield(gpm) G f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /0 r 1 Vt.(. Amount: s completion of well construction to the county health department of the county
where constructed.
Form GW1 North Carolina Department of Environmental Quality-Division of Water i Resources
•
Revised 2-22.201 E