GW1--02164_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inform Ion: Q , `
�lil-r t% Q"/� " i1Y�e} � ? `�i.'� f?t �e�i:'Y.4 t/.1.�ifNyi:'.�Y i t' '
r (J FROM (DESCRIPTION
Well Contractor Name /� ft. ft. 1
LicLi l ft, ft. I ''1
• NC Ma onnaotor Certifloati n Number ':tnd�.>jt7)II�Ii wow (ai ddtiv�itlltl?It5/3ll!I�If Ilc0til6Ffrc:;.
s Pam'? 6, /-}rLG, FROM ft. TO ft. DIAMETER THICKNESStMATERIAL
� )' lei m! 2:51n. R I PVC
Company Name P )I r�J a .1 It i(tglltl its • ,:1Ntiltt 'Mild° IdI'8ltililllb YrA'.rtz j:/%t...::.:.::::..
2.Well Construction Permit#: I ' "2 —O4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit:(Le.UIC,County.Slate,Variance,etc.)
ft. ft. ! In.
tR ft. i , In.
3.Well Use(check well use): �r�• "� av">> - v;� y�
v� I t!": 6
Wank . t 'Yat'<:lT,ti,t,yh 5tz- ; .bt.•.arw./r:`Z.'.. :r:,.a^• ,..'C.;l;':.t.:;.':. ..
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Water Supply Wall: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunloipaUPublia ft, I In.� � ,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, In.
•r 1 tNt �:.)s.y 'j" 'i• z:a`�%tNi�ri'{'KN;�ii;•>i':;;�,r
Industrial/Commercial DResidential Water Supply(shared) ta�Yrt •i ttti#; ,k�,}sK%,�p t Lyk;t<r, *.i,<a:�:':`, ''`:>, '.:�:�'yo%:,<•:y
FROM TO MATERIAL EMPLACEM NT METHOD&AMOUNT
oniWatc • It. >p ft. JC.htn it pvare_d - /,. bet.'
Non-Water Supply Well: - - - - -__ . - /t J
Monitoring Recovery ft, ft.
Injection Well; ft. ft.
Aquifer Recharge ; ' OroundwaterRemediation r. r r 'l- z3.""`' '•s
I :dI!? APlllll ►:1f%% 3l(tbhllttbilfll .:��.•:t• ._ ,z;ss}'s:l :•..:,,.:;: ..
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• Aquifer Storage and Recovery. '.t , Salinity Barrier FROM fL TO rt. MATERIAL
EMPLACEMENT METHOD
:Aquifer Test :!, DStormwater Drainage ,
� ft, ft.
Experimental Technology • [ Subsidence Control
c;..is ,.J r ` :.,..r
Geothermal(Closed Loop)
Tracer f 19Y dRil10t(ntif iklidliiV aili6:e t ttd+$o$f6111:s:,,:•.:re, ,..
� FROM TO DESCRIPTION(color,hardnur,eolUroek type,grain eke,etc.)
.-:Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) rt. " rt. c(l'i r j' lz •
4.Date Well(s)Col{iileted: ;--AS2-24 Well ID# • ,go ft o Tfb r i_)1 j 1"-
5e.Well Location: ; _.r
ft. ft. 5 Lem.,i s.,1
v�r ocS,c)cLfl �1`IAnIo Qr��ls rt. It. . a�� ���7
Feclllt ownerNeme eollltyIDN�(Ifep'pillosblo)
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f 1 to I'�oun a.in /-4I�Y�%1 0OW'12 VGi/I e ft. ft. tRZi;ma:tzn romc,t4n4FIgt(9tp,... . -
Physical Address,City,and Zip �y . 4.z.• " ` •+
ii011t1't 8:'j! t f;rA •aia; i:t`i•'4 ? `t:`v!.%'-n
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F �'ir 4
Li v�co 1� '
County Parcel Identification No.(PiN)
5b,Latitude and longitude in-degrees/minutes/seconds or decimal degreesi • 22.Certiti anon:
(If well Hre1 one ledlong is suffiolont) •Q �,1L � ��'2� 'a ��J� p
Signature ofCartlflad Well Cantrtict Date
6.Is(are)the well(s) Permanent dr 'Temporary
By natusignre-ng tscorhis form,I hereby cari that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: •Yes or wNo - --tvith`IM NCdC 02C.0100 or!S,!NCAC.020..0200 Well Construction Standards and that a
l/70 Is a repair,fill out known well copstkuctlon information and explain the nature oldie copy of this record has been provided to the well owner.
repair under N21 remarksrsction or on the back° this form. 23.Site diagram or additional well details:
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You may use the-back of this page to provide additional well site details or well
8.For Geo,o 1 or Closed ed. Ii Geothermal Wells having the same construction details. You may also attach additional pages if necessary,
• construction,only I OW-I is needed. Ihdioate TOTAL NUMBER of wells §UBMiTTAL INSTRUCTIONS
drilled:
9.Total well depth below land sue rfacd 5 (ft.) 24a.For All Well': Submit tlila form within 30 days of completion of well
Per multiple wells list all depths(f d(Q'erent(exaurple•3®200'and 2®100) construction fo the following:
• 10.Static water level below top of casing: Q, a (ft.) • Division of Water Resources,Information Processing Unit,
If water level is above eashtg,use"+" 1/ 1617 Mall Ser'ico Center,Raleigh,NC 27699-1617
11.Borehole diameter: -' 1 (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: Y 6 t -Nth — construction to the following„ ;
(i.e,auger,rotary,cable,direct push,etc.) • Division of Water Resoulrces,Underground Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
I 1 I
e, nt
3 Method of tests �� 24c.r . .. ter idlulV&Infection Weller In
ition tos form sendingwi t30h days of
13a,Yield(gpm) to
the address(es) above, also(submit ono copy
t �Lc completion of well construotton to the county health department of the county
136.Disinfection type: G )' Amounts where constructed. 1
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Form OW-1 North Carolina Department of 8nvlronmenlel Quality-Division of Water Resources
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Revised 2.22.2016