GW1--02421_Well Construction - GW1_20240422

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%::.,`,.prfnt:Form.
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only;
1.Well C ntractor Infor ation:
•
4 r Y e Ptd cl o •
t::<r� rib � , 5;r ::,. :;,_, . .. .. .
• FROM TO ��DESCRIPTION
Well Contractor Nemo V ft. ft. I
SSJJ� n.. it. 1
NC Well Contractor Certification Number �f $;pi[jh!bti9'e�k$IN0)((o"rtrout(1 id[Waif)`•: I;tT3010V(It�`aiildigili :••' •
1 f ` Rill
/ "Dr TG' FROM TO DIAMETER THICKNESS. MATERIAL
W r l/ L ft. /29 ft, 24 jr f ' SQA A.i . .,p.liG ...
CompanyNamd 17oflNERCyr 31NG let �1Ndli eofiier"tiliMu oilfi6:4'x?':7-;:`
2.Well Construction Permit#:
) 7 O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e..UIC,County,State,Variance,etc.) ft. ft. 1 • In,
3,Well Use(check well use): �:,s r
Water Supply Well: FROM TO ' DIAMETER SLOT SIZE THICKNESS MATERIAL
' . .,Agricultural 0Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Et Residential Water Supply(single) ft, ft, In. .
IndustriaVCommercial t l Water Supply(shared) z: '<=
[� : !i ;y�-;-;�.�� ,^�' ,z �.;'.,
Irrigation FROM TO MATERIAL EMPLACEMEN METHOD&AMOUNT
Non-Water Supply Well: p ft. ,z6 ft. bah eh/If
pares j',� bI{S
..;Monitoring Recovery ft. ft. /
Injection Well: ft. it.
Aquifer Recharge 11111 GroundwaterRemedlatian 'i.osoA'ND1.fr1tA:VrEL''%1'el?DI oribnU intros; .: :: -. 1%,..-:=:` .:;:.;.;`;.
Aquifer Storage and Recovery ,, DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rn
Stormwater Drainage it. ft.
Aquifer Test ,' `•• g
Experimental Technology '`�� Subsidence Control ft. ft.
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Geothermal(Closed Loop) OTracer • F 2b57b 1111901k10.01(4Tri)i :t181:t1Aiiiisiiea't`safiigfild101 ',:: •s•`•:'
FROM TO DESCRIPTION(rotor hardness,sotUrock type,grain the,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) b ft. f 0 ,.ft, d/r a
4.Date Well(s)Chit eleted: 3 '2c 24Well ID# ) 5, ft' /2 6 16 ram./tee.. . ;... .- .; :.'.
It. ft. I. � :. .L...t t• 1....::�•
Sa,Well Location: *4 ..
W we'
A (24A. 1e•/ It.
�" �1�APR2 �,2G�
Facility/Owner A/ L/ J/Owner ms FacilityID#(ifapplicable)
4 4 4 � O t) ,a I -ft. ft, ,i ;,:�.-.fir.,;:-;y t.:i'
If.:tii;T�
• Physical ddress,C ty,and Zip .
1:2r1:)1FEIV1ATiYCSi%;'jg�:a.>, ,�•.;�.i:. •;:;::::
- �, ® :..:
County Parcel identification No.(PIN) '-..
5b.Latitude and longitude In degrees/minutes/seconds or decimal degreesi •
(if well field,one 1at/long is sufficient) 22.Certification:
s a�7 /q N cis /1 f fa W � �� t�' -,�.-�f�4
l Date
1 , Signature ofCertified WellContI cto
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
_ 7.Is this a repair to an existing well: Dyes or ONo ' • with 1SA NCAC 02C.0100 or1SA NCAC 02C.0200 Well Construction Standards and that a
/%this is a repair,Jill out known well bopstruction irtlormatloti and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 reinarkssection or on the back of this 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,only 1 OW-1 is needed. It►dlcate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: y_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J. / A- (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For Multiple wells list all depths((different(example-3@200'and 1Q100) construction to the following:
�7 i
10.Static water level below top of casing: . .6 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: ,� (in.) 24b.For infection Wells:1111 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: r 6 14 �( construction to the following: ,
(i.e.auger,rotary,cable,direct push,etc.) /
Division of Water Resorurees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; • 1636 Mall Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) !b a Method of test; a- / )' 24c.For Water Supply&Injection Wells: in addition to sending the form to
/ / the address(Us) above, also submit one copy of this form within 30 days of
1313,Disinfection type: C I l D I"I Y1 e.. Amount: otZ completion of well construction to the county health department of the county
/ where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016