GW1--02567_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-1.1 For Internal Use Only:
1.Well Contractor I�ormatAn:
,
`Co ✓ �`yl.. _ - 1�i ! F17; ih' FaN.• Y:•ri''.a.!t•. • .. • •:
MOM TO DESCRIPTION
Well Contractor Name Aft. ft,
l36 it. ft. 1 ; •
NZA.1
oil Contractor Certification Number
NC wawa' t�J4 ��,lIt �Q111)Ii(111<n�ndplti�H1b+:`a'• •:FRO
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��' mD+ / M TO DIAMETER THICKNESS _ MATERIAL
LYLG. fh ft. In. r J/f e f;I
Company Na a ..�1 %l N.NfA#Pd ft �iX I ld'6'bilaitrgbilb etnili si'xz:�j:St;i 4:.;),•: : .
2,Well Construction Permit 0: 34)0?3 '7,D�/ "'/ M TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,variance,etc) ft. ft.
In.
ft. ft. i In.
3.Well the(check well use): r �r, ;,, `s)�;:- i::':; •.•. .
b;Mill$ifftelltMi�i rtii::§?:fps'b►?>,.3':;t!i - ;•G:r�.v«.h tz.'. r. 'MATERIAL
a :
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrloultural IN Muniolpal/Public ft. ft, In.
Geothermal.(Heating/Cooling Supply) EiResidentlal Water Supply(single) ft. • • ft. In,
, Industrial/Commercial DResldentlal Water Supply(shared) 1'o400klt; :1i3, 3u; y/mitn 3mmFtai:;:6'as `•,°r.'s'�'{, ?` "• i.- ,.
Irrigation MOM TO 'MATERIAL EMPLACEMENTMETHOD&AMOUNT
rL ./t7 ft, e/ti tin i'', a wee -l l )3 kJ 5
NonrWater3upply Well: __.. ----- Y ' d
• Monitoring • Recovery rt,=, -- it;I ;^—` - — - - - - -- . —
I cation Well: i ft, ft, I
:Aquifer Recharge ®OroundwatecRemediation • g4210AJili10 4Vi iiil' ^•(tti tillint&r;i°Ii .':':~3 :::•gz..s';v ::t:'f:.,';•' �- .•
Aquifer Storage and Recovery „p Salinity Barrier MOM TO .MATERIAL EMPLACEMENT METHOD
Aquifer Test `' % �Stotmwater Drainage ft, ft,f
Experimental Technology ';s!.,:•. D Subsidence Control ft. ft.
Geothermal(Closed Loop) • Tracer
1.401110111 111 04, 0.t(i t1 s Ii-tt#.dIB iRilliii'tilcirtiilifi i il&Y :7,>;•:' f::;;r,' •';::a... .. .
MOM TO DESCRY ION(goisr,h d aa,tolUrork type:aratn size,etc.)
Geothermal(Heating/Cooling�l�Return) 0Other(explain under 021 Remarks) 6 fL q ft. s i&ii J
4.Date Well(s)G'oriilxleted: 7' q't+ Well IDf/ L/) n` Jg - rt. I Y a n i 7e y
Sa,Well Location; I
RQI 1'1. Lag L( it 11. •L.r ft. ft. ; • �i c. ..4. 's,.:.i. V 1._. i'I
• •
- Feollity/Owder Name Faolllty ID#(if epplioable) ft. H, ' n P p,c� G Ili
Ag3 et` eA ft. re. t
Fh sical dress Cit,and Zip L. �,; ;.,.,
Y Y nZ1ltI K$°r'iff.ti'`ifS(:sa;.k:,..vt.:`,i:;:.i,••i.if'r.
lit- {p ep Y/-
County Parcel identifloatfonNd,(PINT. •
5b,Latitude and longitude in degrees/minutes/seconds or decimal degreesi • ' 1
Orwell field,one 1st/long Is autliolent) • 22,Certification; •
35-'575` 71O NI '- Is2. / O7 6W p i Ci �' `3��T
Signat0(eof ertltledWellContractor Date
__ _ __ _6..Is(are)thewell(s) Permanent _dr_E)Temporary-- ; _
By slgning-thi3 jorni.I herebroert(/y-thatdho-wells)=was:(were)_eonsiruered,(n accordance .
7.Is this a repair to an existing well: °Yes or �No ' with 15A NCAC 02C.0100 or%SA NCAC 02C.0200 Well Construction Standards and that a-
ll igs Is a repair,fill out known well bopotructlon Intimation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 reinaPlisection or on the back ethis jonn' 23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed-Loop:Gleothermal Wells having the same You may use the bank of this page to provide additional well site details or well
construction,only I OW-1 is needed, Ihdloato TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: ' f;UBMITTAL INSTRUCTIONS
is
9.Total well depth below land'surface: • . 8 5' ' (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(Pd(p'erenl(example-3tg200'and 1®100) construction to the following:
10.Static water level below top of casing: '7 (ft.) Divlelon of Water Resources,Information Processing Unit,
((water level is above casing,use"+"( 1617 Mall Service Center,Raleigh,NC 27699.1617
11,Borehole diameter: < Om) 24b.For Infection Wells:4 In addition to sanding the form to the address in 24a
above,also submit one copy'of
f this form within 30 days of completion of well
12.Well construction method: r d TA.rI 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 Mall Service Center,Raleigh,NC 276994636
of test; / r 24c.For Water Sunnly di Infection Wells: in addition to sending the form to
13a.Yield(gpm) Method �- the address(es) above, also submit one copy of this form within 30 days of
13b,Disinfection type;
'?ri H 'e- Amount: 1 C.Lk. completion of well constniotion to the county health department of the county
where constructed.
Form OW-1North Carolina Department of Hnvlronmpntal Quality-Division of Water Resources
Revised 2.22.2016