GW1--02565_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,:-
1.Well Contractor Informs ions •
�M i31(t�:lyVlTiIIJTI' .'I>I ,. ,x;... sx:•;r
AA)/ /r `p - . FROM TO i", S la =f,ay.
DESCRIPTION
Well Contractor Name �} ft. ft,
d,l,74 ,L ft. ft.
NC/nW'oll Conheotar Certification Number //�� /� Li •
.4'4 JDt OO OAt'l)1X� Y(ta)' afliiiitiii::ijl�v�Iti IOl 1 INp�/13(hfP itip1i' b►e)`./:`:••.•: -•
C�/P, S Yl/ ei! �/ U yl G, �`M R. T77 ft. DIAMETER
a. In, 51D ft.ki Mp Vic—
Company I ,'OO:]i3 R. A�51 R? OTt • 1GilRif6bilai/ slat'Vi.edl fiYi+. e;1.:,r:,�'7;.::.e,... •
f, J 39 3 TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#s lll///lll//l n, rt. � in.
List all applicable well construction permit:(f.e.UIC,County,State,Variance,de,) In.
f(, ft.3.Well Use(check well use): • t`�71bIIQ1tB Ir?"' .^.ti:t';�.tt 6�,t�J,• S ?':(+:f*JY:{ t� ::.i;:i 1 L::ti:.t•r."":..
<Yili t, 1. feti
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunioipal/Public ft. ft, ; In.
• Geothermal(Heating/Cooling Supply) geResldentiel Water Supply(single) f6 • ft, i ' in,
IndgatrieUCommerciel
Residential Water Supply(shared) zT'll'tlGROfii7.•er Yd ytr gibs Wxi,`•?';i";:trr :rE::;.':f^ :e` =4> as;4t;1N kr>,;?...:.'.
•Irrigstl0ri FROM ,TrrO- MATERIAL.,.y EMPLACEMENT METHOD&AMOUNT
•
Non-Water Supply Well: t0 ft' ,t-.j' ft• }ea,/F'ri i I)0u-red— r.2- h"Lis
- Monitoring ' • DRecovery - ft, ft. �J { .
Injection Well: • • ft, ft.
Aquifer Recharge '1111 Groundwater Remedlation • .iS c W ',• IA t pl{iteSfalft r,i' ,r= :gr, a:i:S'=: : ;.,', s:: .. '.
Aquifer Storage end Recovery DSalinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test _"••'' !.`.• DStormwaterDrainage ft. ft.
Experimental Technology ' •'• QSubsidenoe Control ft, ft. ; .
Geothermal(Closed Loop) DTraoer 1:42.0 14ReVitldifYrVeN(iitt' i 10111io 6111hat±1006I46li K:.4.•'fit'Or ,.;.,..
FROM TO I DESCRIPTION(color,hardne,e,eolUroek type,groin dee,etc.)
Geothermal(Heeting/Cooling Return) lni/Other(explain under#21 Remarks) (b itfft. rt.� V
77 ft.I [ �v t G{�—�y •
4.Date Well(s)'Corbpleteds 4``7 '-,2-11 Well ID# / g rt. )D t.I : Yd-Yl/
5a,Well Location: l a-/' ft. ft,I _.
(ri Na ft. ft'; "i.;.......A.A..,.11` 1..... ,,,,
• Facility/Owner Name L ( Facility ID#�(Inapplicable)
02 -a 6 t( IU 1 't .54\,Oi�7i [,Q�C4 . ft. ft,i - APR 2 e, 2021
fb ft..
Physical dress,Fly,and Zip S •; �: ' .
�j�' Ss'iltiatuAltIL�8�:'<i} .c;P.!!o.t :••rt x`y',•'t'es •`(,:it..; r'• n '�tn
K►ti1 E'u r For [s:=vC '.
County Parcel Identification Nti.(PITS)- • ' •
0(1
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
' (If well field,ono laUlong Is sufficient) •
25.4 602,1 N —82.12 7q y W 0�� a1 -rl��
8ignatufo of Gertliiell c:untreot pat:
6.Is(are)the well(s)�Permanent dr Temporary
By signing this farm,I hereby core,that the welt(:)was(were)constructed in accordance
7.Is this a repair to on existing well: Ot Yes or INNo • with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Coristrucdon Standards and that a
Phis is a repair,JNl out known well cops(ructlon In brtnaliott and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks reckon or on the back Ohl:form 23.Site diagram or additional well details: •
8.For GeoprobelDPT or Cfp'Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
osed-Loo
construction details. You may also attach additional pages if necessary.construction,only 1 OW-1 is needed. Ihdloate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land'surfacei 05� (ft•) 24a.for All Wells: Submit this form within 30 days of completion of well
For rmthtpie wells list all depths(fdtt arent(example.3(0200'and 22(g/00') construction to the following:
10.Static water level below top of casing: y (ft.) Divlelon of W•I,ter Resources,Information Processing Unit,
If water level is above casing,use"+/' 1617 Mali Service( Center,Raleigh,NC 27699.1617
11,Borehole•diamotert /d (in.) 24b,for Injection Wells::In addition to sending the form to the address in 24a
12.Well construction method: rD r
-}-4-r Y above,also submit one copy of this form within 30 days of completion of well
construction to the following: "
(I.o.auger,rotary,cable,direct push,oto.) •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mall1Service Center,Raleigh,NC 27699.1636
/� Method of tests a--1 l'` 24c,For Water Supply&Infection Wells: In addition to sending the form tc
13a.Yield(gpm) I A - the addresses) above, also submit ono copy of this form within 30 days of
type: ewe) /r1 e./ Amount: completion of well construction to the county health department of the count)
13b,Disinfection D r where constructed. .
Form OW-I • North Carolina Department of Environmental Quality-TO/talon of water Resources
{levlaed 2.22.201t
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