GW1--02580_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1,Well
�}�'1�jon�}tractor Information:/�r(/J/i/] A (�'�y j { �I�.j�q�y�[� ,
f�Vt~lr� / //�i� (� __ - i'iA4/*it i05 /.�,('1�1 ERi i iiliV i r�Yl.�,w/•'i N'Y�'`,e6 ., :f i'. ::f.�• ... .. •!
FROM TO ti, DESCRIPTION
Well ContraotorName ft. f6 I 1
2155A n. fLI ►
NC W I Contractor Certification Number 5 l n,*I $;')J)116� (£'Orl)lltftnl o• i)J l It tq 0 A 5 )�pl;(I/pdpil'e tl1�S%;.:;..•: i
� L FROM TO DIAMETER , THICKNESS ^ MATERIAL
!/I/t�i� fizfriy �,f,yL G. I R. �9 ft. 'r a �j „z j j✓G
Company Name U Q�") `X6 R 'ittt11l 1Ci�d l titela11 )t ldletSglJpfi•IlY} i f-,'kA�.':.=.A...f:::. .:.'
�,f Fl� TO 'DIAMETER THICKNESS MATERIAL
2.Well Construction Permit fit [ice j In.
List all applicable well constuclion permits(he,UIC,County,Slate,Variance,etch ft. ft,
ft. ft. In.
3.Well Use(check well use): b. (, ,. --,r> •r. .i. ,b ,>r5 s i Gx7:`r ut^'s'.S{ r:;,'r?c?:::ir:.r'.r;,,. ...;
Dl71SGl katit Fitts-:�vn3. •rs,"K.e-.-
Wetersupply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • III Munioipal/Publio ft, R. In.
Geothermal(Heating/Cooling Supply) EResidentlal Water Supply(Biagio) ft, R. f In, .
Industrial/Commercial Residential Water Supply(sharcd) Id r. t;•a�'Fl� ,,�;:k;�/v;, (rt ""f�}• �T•;�`:'>•'>=;�",=I:'�:�/rye: r;s:T�<;'=::••,.
<dl�t:f>�t#.Cf .f a�3�.s =`��.'„�fr,r�.r�.-:��:� ry:•tt:..C.:,.1.a:.:.t4;�,5. •t..
.:Irrigation FROM TO I MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: b ft. Az) ft. ; j 64-21c1 t't✓ f D LCYL'I—i Z- J.
Monitoring _ _ - ORecovery it ft. .
Injection Well: ft, It.
Aquifer Recharge •
©OroundwaterRemedlation • Y192$Aiipt " + L+tI?All-+(II( lflte5hlt±� ,:2'kk ;':'•`:3. 1r'';W =1~i:r.:•.;"•::.• •Y
Aquifer Storage and Recovery jSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test .• �: DStormwater Drainage n. ft.
Experimental Technology .•‘ `\ti.',:i . DSubsidenoe Control ft. - ft.
Geothermal(Closed Loop) ? oTraaer ls1'�;J"IlleSt11t1bils : t(att ;i'att>ililer)allik°taieiffeieo 'A�iS4?:).:�,••.��i:•.:;: ',::._•••
FROM TO DESCRIPTION(color,hsrdnrrr,soil/rock type,grain flu,ale.)
<Geothermal(Heating/Cooling Return) nOther(explain under 021 Remarks) D fi, P2,9 ft. di i^1, 5 .�r.ci/� .
/I=3 �
4.Date Well(s)tbmRleled: Well IDS SD n' n.9'ft. t yi /
ft. R. J
Sa,RWell Locations/� f •
ft, ft. �`. •- ' :' ' ' ' •.I
(3y)Alt ! ra-A l %-V, • '. „..., •G_-'r ;: �•..t._�'
FacilityIDA Ifs lloable ft. ft.
Favll(ty/Ogwne�r Name ( •
r PP ) �{f K (j Z Z4
�,tiz.si _,,,,„I 1 Q); t�Y, 1))eto _ rt. ft. ;
Physical Address,City,and Zlp J,� �yy fL { ft, I _in .1e..,,';,Z-'r o. t 71-c`3,�u-,q,tJ,
J� /5 1 YSM•VI • Sl�r:1 '��'.lY{..lu.rj�\t`•P•.i Ne.:4.••�•{:•.4.., 4.2•/4••a;.i. :i
. County Parcel identification bid.(PiN)• -. • • . ,
5b.Latitude and longitude In degrees/minutes/seconds or decimal degreesi
1 ,
(If wall field,one let/long is sumolont) • 22.Certification:
55:c597.2. N 97. 4lbgl w •1 d„/ '2/ 4
i i i SignatuteafQortlttad Well Contractor Date
6.Is(are)the well(s) Permanent dr �Tamporary
By signing this joint,I hereby cerl(ly that the walls)was(were)constructed in accordance
7.Is this a repair to an existing well: 'DYes -or allo " with 1SA NCAC 01C.0100 or 1SA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,Jill out known well copsiructon ly/brmatlon and explain the stature oldie Copy of this record has been provided to the wall owner.
repair under All reinNkrsacrlon or on the back of rhlajorvr. 23.Site diagram or additional well details: •
8,For Geoprobe/DPT or Ciosed?I;ooji'Oeothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l OW-1 ie needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages If necessary.
• _ drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below lana'su /y
rfaces • !v5 (ft') 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(Qerert!(example-3@200'andd 1@)100') construction to the folloWing:
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10.Static water level below top of casing: /5 (ft.) • D1vltton of Water tea•Resources,Information Processing Unit,
((water[wells above casing,use"+"/ 1617 MalllService Center,Raleigh,NC 27699-1617
11.Borehole diameter:- U'14 •
(In.) 24b.For Injection Weals:(In addition to sending the form to the address in 24a
above,also submit one Dopy of this form within 30 days of completion of well
12.Well construction method: r 6-teLky construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636'Waif Service Center,Raleigh,NC 27699-1636
, 24c.For Water Supply!&inlection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: / Y' the address(es) above, also submit one copy of this form within 30 days of
GJi- 0 y!YL e. Amount: J. /%/.� completion of well oonstr rct(on to the county health department of the county
mil Disinfection type: where constructed. 1
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Form OW-1 North Carolina Department of Environmental Quality•Division of Watl r.Resources
Revised 2.22.2016
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