GW1--02403_Well Construction - GW1_20240423

ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor IInformat�i('Q/�ntjj. alma
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TO DESCRIPTION I
Well ConlrectodNemo ft, ft,
ft. ft.
NC W II Contractor Certification Number •
. Jl xE (ti�iigft (1'ot�t i�iJlaiaatiAli jtll POl 13 ffiii' iCtiiilit:;:•;.••: •
r G` FROM TO DIAMETER THICKNESS MATERIA6
NC
l/I/t?�l Ill�1�v1 [�b�, I ft. /a,/ift. I .i S KNEES !j_ L
CompanyNafie 1 . fl 'A lil'{ii'O14l 1NOI,(J otlWn1' 8loieii�fp;4]i)zt`,1:,.,_k- :.A••• r•
Skdot. - to2�9
2.Well Construction Permit#; FROM TO DIAMETER . THICKNESS `MATERIAL
List all applicable well construction permits(I.e.UIC,County Stale,Variance,etc.)
n, ft. In.' '
It. ft. In,
3.Well Use(check well use): ;: .::
' hhg i$ Fi�a`'e4timswirapoii;:T,�"s(3 rtifip- «'ilc`;,.. :a ;,
Water Supply Well: • r FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. In. 1
Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ft. H. In. I I •
Industrial/Commercial 0Residential Water Supply(shared) Ig)fa` l rfry4 ;/s v, Y; <<,mf;f io`y. "r'._n s`:F';::<<,=3omd Y<,--t=; :': ''
:Irrigation FROM TO MATERIAL ' EMPLACEMENT &METHOD AMOUNT
Non-Water Supply Well: • 0 ft, o't,d ft. b e Ytte/t fie.;.D ared- I A'j a y s
Monitoring Recovery - - • ft. ..ft.
Injection Well; ft. ft.
Agtilfer Recharge III Groundwater Romediation •
'al•970e1•)!I1Y7.OR'iTT:'4'igi�:'•.R.Ab `(Ifi•dii4egiit I kr.4As`-:co•::= .::54.''='s' _"'>::"••
Aquifer Storage and Recovery (3Sslinky Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test " DStormwater Drainage ft. ft.
•
Experimental Technology •,: QSubsldence Control
Tracer r .; '111L11 p , .,;r- •,.c,.••
Geothermal(Closed Loop) FROM fi)IdilalSOt(att 'atigftiw?tY`a7ION(color,hardneit,tolU r•:
FROM TO DESCRIPTION{color,herdnerr,rolUrack type,grain size,etc.)
t Geothermal(Heating/Cooling Return) nOther(explain under RI Remarks) D ft. /). , ft. ` t
i r r mile-)) clay
4.Date Well(s)Cointileted: 5—o2e2r�1 Well ID# I,Z 5n' ,t' tt. �imt i �'e. •
5a.Well Loc 1 tiont ft, rt. j. "1., t r •`e , r�
ft. ft. j
A -rt / 1 II�r •; ' ft. ft. �f' .� �G2 .
Fscilily/Owntr Name p ,/� Faultily ID#(if epplloable) ! -
�/ 14!! ie b y T^' . ft R.
‘:;:r;.�_ ;fDJ t. 'l�w,--•`�'
Physical Address,City,and Zip i/ ;. ,u • :M ,.,
$st1ml�tFf S" :}k:==c�'1''4.. :j;i:. jai}:t?vi.••:.�y:•�:'
1v1�no�•IJe
County Parcel Identification No.(PiN) -: •
I
Sb,Latitude and longitude in degrees/minutes/seconds or decimal degreesi'• ' I
(If well field,one tat/long Is sufficient) • 22.Certification;
35.570921 .41
N -81.90663 a n e
l Signature ofC Zia-4/3/1_
Well Cont for I Date
6.Is(are)the well(s) Permanent dr �'femporary f
By signing this form.I hereby cep*that the well(s)was(were)constructed M accordance
7.Is this a repair to en-exlsting well: ^ DYes -or,elNo-'• -- - -- .. _with ISA NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jlll out known well copslruction information and explain the nature of the copy of this record has been provided 011ie Well owner.
repair under N21 reinarkrsectlon or on the back OW form. 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed=Loop 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-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /. _ SUBMITTAL INSTRUCTiONS!
9,Total well depth below land surface: J5 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ud(/erent(example.3Q200'and 22@100) construction to the following: I '
10.Static water level below top of casing: O 0 l (ft.) Division of Water Resources,Information Processing Unit,
((water level is above casing,use"+"(/ 1617 Mall Service f enter,Raleigh,NC 27699-1617
ILBorehole diameter: (C /4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one o0 of this form within 30 days of completion of well
12.Well construction method: t ' 1 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
Method of test; l -/ V4 24c.For Water Suably&Intel tton Wells; in addition to sending the form to
13a.Yield(gpm) c the address(es) above, also submit one copy of this form within 30 days of
G��O Y I Y1 C Amount: 2 6.4.4 6 _ completion of well construction to the'county health department of the county
13b,Disinfection type: 1 where constructed.
i Form GW-1 North Carolina Department of Environmental Quality-Division of Water MammaRevised 2-22.2016