GW1--02399_Well Construction - GW1_20240423

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—WELL CONSTRUCTION RECORD (GW-ll For Internal Use Only:
1.Well Coplractor Informal on: n t j y is •j
( ��// /qLJ l i1NAf rl �-^•'' A J aZ Y:?l'c`'i''' r'
[Na r e 9 FROM TIE DESCRIPTION
WeIlContrnctorNeme ft. n•
)-7 c'T,c--A- n, ft.
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NC wolf C teaclor Certlltioetlo/1n WO
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l AJ vv V"l I �J !iL 6, incG • FROM ft. TO ft. DIAMETER(n. �/1 3/ I MATERIAL
Company Name 7 tx ltl<Nt R n Q Ql1 % otlSitt�n lIl`o�Ieilg1b sY=' ':;
/ ( S'•3 - ,'29 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. In.
List all applicable well construction permits(i.e.UlC,County,State,Variance,etc.) In.
n. ft.
3.Well Use(check well use): :,: 1 ,; Ii;:'jc:A ,'?: F t. f7 7r ry .y,ciw%. :i r:'::'^ 'i:-e?.'`
:11..k3'L12tEil1l .,� tv::
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS f MATERIAL
Agricultural
DMunioipal/Public n. ft. In.
Geothermal(Heating/Cooling Supply) at Residential Water Supply(single) ft, it. In•
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Industrial/Commercial DResidential Water Supply(shared) NBt GfR f ,+ ,,,,, , rv, lag;;.;, t >
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
n- ti D It, 7 ft. be/z7en s / o%�re)—l) �jash-
NonWater Supply Well:
Monitoring [Recovery rt. it.
InJecdon Well: ft. n
Aquifer Recharge ®Oroundweter Remedlat(on 1.4a$; pllgaV;>;i:PAb (Uipifiicglll °x r;` • `'•--;. :OD
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Aquifer Storage and Recovery • OSalinity Barrier FROM n TO ft. MATERIAL EMPLACEMENT METH
Aquifer Test 'N. oStormwater Drainage •
Experimental Technology DSubaldence Control ft. ft.
Geothermal(Closed Loop) DTracer T<YB iq A011,0 100api gillilaiiili+6e trtlfri6oits.id): -. <
FROM TO DESCRIPTION(color,hordoss,sotUroek type,&rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) RO ft, [fit/t fL d;r t (co G f Lroc
4.Date Well(s)Cothpletedr 3 /I�Z7 Well ID# • In D n. f��j-dl,Oft. (l o Qn/f'& - /
( ft, n• J
5a.Well Location: It. •
n.
Fscliity/Owner// m
Name,, q Faoility!DM(if applicable)
rt.. ft.
7 I U ///��/d pG/�1.�X a ft. ft. Irv:..,
1 ft. ft 1(
Physical Address,City,and Zip _,,.,. • };lit` k,
L-iYIGd[Yt-
County Parcel Identification No.(PIN) -. - -
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees; 22.Certification;
(if welt field,one let/long is sufficient) •�j , I )1 r � � ,/ Q
.7 '44 .1/ N — RI, OJ Li4 W �` ^a `�
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t Signature of t7ertiAed Well Contractor ppf0
6.Is(are)the well(s) Permanent sir `Temporary
By signing this form.I hereby eert(fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYea or IffiNo • with 1JA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided tc the well owner.
Psis/s a repair,Jill out known well aopstruc!!on IgJormorlou and explain the nature of the 23.Site diagram or additional well details:
repair under IPI reinarkr-rectlon or on the back of this form.
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You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed ed. I dicat'Geo hermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 OW-1 is needed. Ihdioete TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: tJ 0b (ft.) 24a.For All Well`: Submit this form within 30 days of completion of well
For multiple wells list all depths(f d(Qerent(example-3®200'and 201100') construction to the following:
10.Static water level below top of casing: Ike' (ft.) - Division of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
((water level is above easing,use"+`,
11.Borehole diameter: f `� (in.? 24b.For Injection 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: ) 0'a ry construction to the following:
(i.e.auger,rotary,cable,direct push,eto.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mall Service Center,Raleigh,NC 27699-1636
t
Amount: 24c.r" later Sup tY&Inlectlon Wells: In addition to sending the form to
13a.Yield(gpm) Method of teat: //� the address(es) above, also submit one copy of this form within 30 days of
� C u -4completion of well construction to the county health department of the county
13b.Disinfection type: (r�1OY I Yt�' where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resource
Revised 2.22.2016