GW1--02474_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD(GW-11 . For Internal Use Only:
1.Well Contractorarli/di
Innffirmat onns j]� , •
'd"// t - �MM'4FJRAT �r�.cl: X -'•,S••�l f'.?:.*w"�ii-:f�:i':•.. .': . •,. .. •,
J� T. DESCRIPTION
WeIIConlraclorNeme / ft, :::
H
IL ft. •
NC Well Contractor Certification Number ///��� it:ga iS01111E)1Y `AAigl)V Y(t'8l' i)I dlCVa71())tQ f)ih31�Ti1�fi at ul('c��tbyr` ~:
S !,1/ /,�� FROM TO DIAMETER THICKNESS l MATERIAL
'� �. �G, ft. M r6 ')151n, ell I` /_• e,
Company' Nsm6 .7�i; ASL`a,:QI,L)fib'illOoBe111t)itiYiYa`•bzi=:,'1i:4'}: :A
�1AJ )e/24 r- O 0 t 2. FROM TO DIAMETER In. THICKNESS MATERIAL
2,Well Construction Permit#I fv���/ow `Z' ft. tt� +,
List all applicable well construction permits(I.e.Ell ,County,State,Variance,etc.) in.
ft. ft. 1 ;
3.Well Supply ells well use)t )'Alai a }kit �� ;edit ; ty ;r-:fist fr. •1.. ,'; ::r::;,'::y�'::: :.r•:�:,'••...
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q�'Muniol al/Public ft, ft. I : In.
p
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. • ft. I I in, .
�Residettia!Water Supply(shared) ��<i::l:`k�Y' d 7t'4=t':e, ').f. 'tl'`'' w'°•i"`^::::•
IndustdaUCommerclal PPY �a�fl6li�C#.�J�;�;>?A�)�'w...�„Y�.�.�:L�4;S:��<y,.E�...?�.._t::�.�:Te,..,,.._.r.�..,r.:x.:..:.
FROM TO MATE IAL EMPLACEMENT METHODr&AMOUNT
.;Irrigation a ft, ,I8 ft• h • e y/)tp, iO D l U4 C1--L.- 4. '15
Non-Water Supply Well: ., �/
Monitoring ' ' DRecovery ft. ft.
•
Injection Well: ft. rt. •
Aquifer Recharge ©Groundwater Remediation • t 7 .)4g , L; A Bd tit ki#I(eNliil;Y,kr��'••••,''•,:z3',t �,`:`,`'••'":r;.'.r`"• '• •:
Aquifer Storage and Recovery' oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Stoimwater Drainage ft. ft
Aquifer Test
Experimental Technology •!, . ,OSubsldenoe Control ft. ft.
1:12�;101t1l(NOU` Of;Rile! tti11111Miffansl e.,lfini'a idii�!)4A-,.t.g.M;r•• '',::•',—Oeothermel(Closed Loop) • �Traoer FROM TO DESCRIPTION(color,hardness,soll/roek pew groin size,etc.)
Geothermal(Renting/Cooling Return) 130ther(explain under#21 Remarks) 0 it. 1 7
q ft, j i1,.•./-i r e-). ./zt.V
2 F Well ID# • /g d R' 4 5ft• ' rail?few rt, IL /
4.Date Well(s)'CoinQleted: �" l
5a,Well Lop Won: A •
rt, ft.
Pe4re (1.r-V4z6.�• • ft. ft. APRC��4
•
J
Facility/Owner
Name Facility ID#(if applicable)
'l OL p ft. ft. IT S::•r v.• ''.-1 ?, ^.
A- •C�Ya vas lam+ . rt. rt. �."k�.
Phyalcal�s(drese,`C�h ,and Zip J„':1 'or? :Y' . ,:,,to tf::....:;}w•*1.,:.• ,,.•: "
ul"h�r' ord
County Parcel Identification NO.(Pi111) •
-
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees; ' 22.Certification:
(If well field,one let/long la sufficient) •
. :Lfl,2-*11 N — P1..II*/ 7 W Si ( l' 1 - ��4
Pate
c s SlgnatuLaoftrertltiedWellCont or
6.Is(are)the well(s) Permanent dr Temporary
By signing this formb l hereby cert(/y that the well(s)was(were)constructed In accordance
- 7.Ie this a repair to an existing well; ,P Yea or_MtNo ' with 1JA NCAC 02C.0100 or 13A NC4C 02C.0200 Well Construction Standards and that a
((lids is a repalr,Jlli out known Well bopstraction hf/brmatlou and explain the nature of the copy of this record has been provided to the-well owner.
repair under NJ1 rmnarkrsecrlo,i or on the back tjtlds jaw,. 23.Site diagram or additional well details:
•
` You•may use the back of this page to provddo additional well site details or well
8.For Geon,o only 1 OW-I Closed-paed. Ili loate TO A WellsU havingBE the wellssam construction details. You may also attach additional pages if necessary.
construction, 1 Is'needed, Ihdioate TOTAL NUMBER of SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land•surfacet • T• 0S (ft') 24a.For All Wellg: Submit this form within 30 days of completion of well
For multiple wells list all depths if derma(example-3®200'and 2t11100' construction to the following:
I (ft.) Dlvlslon of Water Resources,Information Processing Unit,-
10.Static water level below top of casings 1617 Mall Service Center,Raleigh,NC 27699-1617
Uwater level Is above easing,use"+"� •
11.Borehole diameters t� /4- (in.) 24b.For injection Wellas In addition to sending the form to the address in 24aova r above,also submit oneloopy of this form within 30 days of completion of well
12.Well construction mathodt
construction to the following;
(I.e,auger,rosary,cable,direotpueh,aso.) Division of Water Resources,Underground Injection Control Program,
( • 1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
Method of tests 24c.For Water S ARIL Rc Infection 1,ygjlgt In addition to sending the form tc
13a.Yield(gpm) l �! the addresses) above,'also submit ono copy of this form within 30 days of
0 l„ �� at G1,C s completion of well construction to the county health department of the count)
13b.Disinfection type: Amount: where constructed.
Form OW-1 North Carolina Department of Einvironmental Quality•Division of Water Resources
Revised 2.22.201 t