GW1--02596_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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FROM T.� DESCRIPTION
Well Contractor Name ft. ft. i I ,
*5-4 j A - ft. ft. .'
NC/I)Conheotor Certification Number 1;5110t10'>9ll°W I I ilfi'.c'"i)J ' 0d1Cv ll tOR IN}1';(f��t Ullciihial ;:; •'• .
tt /��l FROM.
TO DIAMETER THICKNESS MATERIAL
'L s' i/de./f V t't l-)r�,Lkf e. rL ft: / i,5 In. A R -1 VG
CompanyNam� /H. i . /� Gf t:1'BP RVA I�.t�`l010.I II'I.. &ilat7 •• litit'stilt`fiitiblziWy.. '::,::.;,;.5: :.
2.Well Construction Permit II: �/!✓ —;O23—)9�,`?G� FROM TO DIAMETER THICKNESS • MATERIAL
List all applicable well construction permits(1.e.UIC,County,Slate,Variance,etc.)
ft. t6 I In.
3. ft. ft. I In.
Water Suppltse y Wellk:
well use): �tht8'411ta W.A1xt ?' K03.:ligi�r c>•}::rail; ;.t:,K4i...;fi*.'i:ti*:''ei;. i':.-..•.
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Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural 'DMunicipal/Public ft. ft. In.i
Geothermal(Heating/Cooling Supply) ..Residential Water Supply(single) • ft, ft, In.
Residential Water supply(shared) I: 7RZW + .,> •'ts',[°'`'=� �c :s .y.:: ='3: +,M�=15-.i'?•t: -
_;Industrial/Commercial •� P <.11�(f�l !I�+jfi.:Ina:='='t;+rue'�i.:.h:=:N�14ir.Fr�iL� �': ?`•. ' . _.:���..
Irrigation . - . _ FROM TO rMATAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: _ ' - - -' - P .'. ,20.. tt. bob e Yl rife, po 1.LY2. )- `dt. 1-A�5
Monitoring Recovery ft., • It. v
Injection Well; • ft. ft.
Aquifer Recharge III Groundwater Remediation ,•:' - ,• ��
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:.id r ••i!I!11)1 It'A:WiEi item'1(if{ )ntwi110,c;:;,max":._': <.# ;;;i::i <::..,,>^.. ., .:>:•
Aquifer Storage and Recovery ... DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test -- ,`a‘•' DStormwater Drainage 'it, ft. 1
Experimental Technology `�;it DSubsidence.Control It. ft.
Geothermal(Closed Loop) DTracer 140 tilllldfildr(11Iit l(dtt ot,Nt11l1etY.�iiifie"iltidl rifettee : •. •..:.:i;':• ?•r•°."
FROM TO D ICRiPTiONkoIor,hardnen,iolUrock type,grain eke,etc.)
Geothermal(Heating/Cooling Return))' Elother(explain under#21 Remarks) • n. it, I� •(- �y� _41.xy Fv ih
4.Date Well(s)Completed: ' A7 4 Well ID# 4,0 ft, / ft, A, k, y_i' e
So, .A Location; _ ) ld e-r er it. it. I' s ,•",_�"r g"'t �.t' t'
,�Q Vlln n Xh R. tt. •
Facility/Ownor Name Facility ID#(if applicable) APR 2 3 2074
r1 ,13 A, .6D it aYee C lit? `/e > e% ft.• ft. '
Physics Addr se,City,and Zip �.y �,, l D `O-19'Y3'
?t'vlliill•/iIV►,1iI)4`:''':t�::.;•ilT/,vla;,:"•y.?,J�:},.i'i�:•.`r.�.�'fY . :.i'•.:..
County Parcel identltication No.(PIN) -. ,
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees i •"
(If well field,one loot/long Is sufficient) 22.Certification; •
3.6:6,Z 2-?-d- N — g6' clit1+6r W el-Z/1-d/ P' :-//// 4 '
` Signature of Certified Well Contractor Date
6.Is(are)the well(s)iPermanent dr OTemporary
- Ay signing this;PM:/hereby cerl(/y'.that the=well(s)was-(were):constructed in accordance
7.Is this a repair to an existing well: *Yes or No ' with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and Ihat a
(f Ihls Is a repelr,Jill out known well aopsieuctionJrylbrmation and explain the nature of the copy of this record has been provided so the well owner.
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repair under#1l reinarkssection or on the back Ofthlsform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPTor Closed=Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells 1
drilled: • SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface; �L � (ft.) 24a.For All Wells; Submit this form within 30 days of completion of well
For tnuhiple wells list all depths(l'd(Q'ereml(example•3®100'and 1®100)
construction to the following: l'
10.Static water level below top of casing: M.) Division of Water Res ources,Information Processing Unit,
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((water level Is above casing,use/"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (�/� (in.) •
24b.For Inteetlon Wells: In addition to sending the form to the address in 24a
`(�'010. above,also submit one copy of this form within 30 days of completion of well
12.Well construction methods construction to the following: ,
(i.e.auger,rolery,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mall Service Center,Raleigh,NC 27699-1636
114 24c.For Water Sunniv&Infection Welts: In addition to sending the form to
13a.Yleld(gpm) O Method of test: Q the address(es) above, also submit one copy of this form within 30 days of
? completion of well construction to the county health department of the county
• 13b.Dlslnfectton type: ' I p r't 11� Amounts ' Gu 1/15 where constructed. I .
Form OW-I North Carolina Department of Environmental Quality•Division of Water Resource
Revised 2-22.2016
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