GW1--02566_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1,Well Contractor Info motto t J J� i (�yyj ��[• )j�I tI
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MOM 'DESCRIPTION
WaIIConlreotorNama ft. ft. II I
NC W i Contrsotor Cordiioetlo Number 4 _ moon Gd'SI Gtl'(ro tiiltd§i'k3.liN�lii�to G )n1�11 s. tiCtial '/": ••:
l�4 lil��il / ( G�/ �"Gr /M .ft. TO I DIAMETER THICKNESS l t. I(0 l�.ln: �/1)R.21 MATERIAL
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Company Name/ / E ,• }
`�%1'6F�NB11 ri�1T�i`SQI+` I ti'/�e'iiCOR' �11I1`oaetlltll6$1`tA:�at;/::s.:r:.r..;•'�is�st::• :••:
1 `3 1,. J(0 L FROM TO t DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#t vvvVVV V` ! tt, ft. ! in.
List all applicable well construction permits(l.e.UiC, ounUy,State,Variance,etch In.
ft. ft. '
3.Well Use(check well use): • I• ::. 45.'»iti>�: liri g?IS3a"1;f "}l?i++x7rJrw% r:':.i r.�.rr•'s> ,'t,:'::e::2
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Water Supply Well: j FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural " DMuniolpal/Public ft, ft, ' ' hi.
Geothermal(Heating/Cooling Supply) ogResidantiel Water Supply(single) ft. ft. I . in, .
Industrial/Commercial DReeldential Water Supply(shared) i tM-17 Slilr 1 4 F;,yi.; + ti,,,xA>ti :4 i�=•f.dtli§W.g )s:,Y:< :;,. r."
FROM TO MATERIAL f EMPLACEMENT METHOD&AMOUNT
.;Non-Waternigation tL " fL ./je.xli,il pDI.IYegi //a s
Supply Well:
Monitoring ' ' • )Recovery ft. . ft. ' -
Injection Well: ft,• ft.
Aqulfer Recharge OroundwaterRemediation • •:;970410l4)M014140'i t h lleNftli f*.:/4•re..:;~?^' 1*4`•:`: '0;:•r;.'' •
, 1
Aquifer Storage and Recovery Salinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
Stotmwater Drainage IL tt,
Aquifer Test `• r
Experimental Technology,:t,' .,• (. Subsldenoo Control ft. , ft,
1,zdNoit� �izaab.(cah ,rN;h�aSllldatiibaldrnrrdf ::af'..:,; ;::'.:• ,.:.,... .,
Geothermal(Closed Loop) Tracer FROM TO DESC IPTION(color,hordnen,,olttrock type,Rraln,I:e,etc.)
Geothermal(Heating/CoolinJJg��Retturn) l�� •
Other(explain under#21 Remarks) 0 ft. /;411. 1 i y.t/ I e-(eL�
4.Date Well(s)'Coitigleteds'T Ie�.7 Well ID# • f )5 it /, Li,57t. i : riu'iJ/
• . ft. ft.i •.
Sa.W//elll Location: ft. ft.
_ Facility/Owner Name Faolllt IDq(If applicable) ft. It I i "a y,•L ;i.:: yr r ,._,
4 g . gj ri4.0i S. e;, n. ft., APR 2 3. ZOZ
rL ft.i � .. .
Physlcaajddress"; Ity,and Zip., +.j. ;t'. y' {;_, .",�i .. ..
//((���� s' :;1 5,+�:!s:i fe4aal.Sw.ir;.::v"Il; tom`7::?..o-:+% .�. .lT ;� •
r r� �•�S�O; vt�
County Parcel idontltication Nti,(Ply)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degreesi . ' i'
(if well field,one let/long Is sufficient) • 22.Certifications
t.5. 453 16 N -97-r, DO .2-6 w 'A �_'./ 9=oZ
��� f Date
Slgnatur.e of CeAlaad Well Contractor6.Is(are)the well(s) Permanent fir Temporary
By signing fits,foray,I hereby cert(/y that the well(s)was(were)constructed In accordance
- - -7.is this a repair to an a sting trails"• Yes, or,BNt+= ----- with 134 NCAC 01C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
OM is a repair,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner:
repair under 021 reinptkssectlon or on the back of this fmws. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the book of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. lhdloate TOTAL NUMBER of walla
construction details. You.may also attach additional pages if necessary.
SUBMITTAL IN$TRUGTIONS
• . drilled:
9.Total well depth below larid•surfacel (ft.) 24a,For All Wells: Submit this form within 30 days of completion of well
Per multiple wells list all depths(fd(i7erennt(example-3®100 and 2®1001 construction to the following:
10.Static water level below top of casings c. b (ft.) Divission of Water Resources,Information Processing Unit,
//water level Is above casing,use"+" / 1617 Mali Service Center,Raleigh,NC 27699-1617
. 11.Borehole diameter: AT (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
•
�� I
12.Well construction method) r construction to the following:
(i.e.auger,rotary,cable,direct push,ohs.) I
Division of Water Resources,Underground'Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
I
/f Method of testi (/ Y. 24c.For Water Suanly&infection Wells: In addition to sending the form to
13b,Disinfection type: �i11
13a.Yield(gpm) K addresses) above, also submit ono copy of this form within 30 days of
li"i/'i t? Amounts completion of well construction to the county health department of the county
where constmoted. 1
Form OW-I North Carolina Depadmentofnnvironmontai Quality•Division of Water Rasourcea
Revised 2-22.2016