GW1--02597_Well Construction - GW1_20240426

. WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: i
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1.WellContractor
Informatlo .
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o-rrett/ jell _ _ � T 7Ml Y `i" FT
uy-rCi'. , ... • •i
Wall Contractor Name PROM TO DESCRIPTION
ft. ft. I �
454 5A It, ft, ;
NC W I Contractor Certllioetlon Number •
_4i8,'iJbp�lYA"�JYJ (fed'fifJldlii��iit0 �11 �1i((III ilcsdilt :is
j'( 6 J it� FROM rt' TO D' DIAMETER n, THICKNESS MATERIAL
�� S Lam) ) 'flu c L / ` ti g, 1 zsT SDR�-1 PVC-
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W Company Nemo ;) R(..0'A ,(1llEf•itipRII!,lf'iYdiYS'tiCO'I't�v l'o"tana I�R,K :5•.-•... '.'�.:::'
1 r L�� TO 'DIAMETER VHICKNESR MATERIAL
Well Construction Permit#t ( I rt.
List all applicable well construction perndls(he.UIC,County,State,Variance,etc) r(, •
rt, ft. in,
3.Well Use(check well use): fy [` t a �t.?y u;:..,rr,y r .7 r
hl$Q 14:inia?�f iiie,1:+„,t3h'r:1l3?�e�i;i4b:YiPAP--,4 ..•>:..�.r..i�•M,I�'•:. f:,•.,.. i
Water Supply Well: • `FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural . DMunioipal/Public cc, rt. In.
Geothermal(Heating/Cooling Supply) ligResidential Water Supply(single) r(, ' • ft, In. .
Industrial/Commercial DResidential Water Supply(shared) . (.altatoo L, ,,,:;y i , g?h's, ;4 syg,,r 5. :•=;'(:it.q. "` --:.,
•Irrigation FROM TO MATER AL �/- EMPLACEME TMETHOD&AMOUNT
Non-Water Supply Well: Q IL ft' en•�'eyt,Je i yt,Y -'f ,�GJ S
-- - — Monitoring---- . ._ - --Recovery_- —_ _ft. ft. ' • V
I action Weill ft, n• ' '
Aquifer Recharge It Groundwater Remediation • ':07'ItAJ�Ir#iit:: A0• ti(i h t M110161W3sry>,t' 3;:%::^I-91-: ':;:'r.;•,:'` s••.•
Aquifer Storage and Recovery ' iSalinity Barrier FROM TO 'MATERIAL EMPLACEMENT METHOD
A ulferTest . ``• '••`. QStormwater Drainage ft, ft,
Experimental Technology , t': DSubsldenco Control ft. - • ft.
Tracer 14.0312Y.0131111.loll;1:11E(pft4ph`•Jit1.Sf11dfshills'F`�1fdiiM'c taaii4l:%.•,:;ii;;r,' ,.;.,..
Geothermal(Closed Loop)' ,.r FROM TO .DESCRIPTION(color,hardneu,solVrock Pe,;train size,etc.)
:.Geothermal(Heating/Cooling Return) 01Other(explain under#21 Remarks)�/ r
7) rt. /7I1 rt. di r't; SAwd-q A ire- m•oc.
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4.Date Well(s)Completeds'Y • Well ID# 19b IIdg , ft' 4 V 1'1" a �l
5a.Well Location: • ft. ft. 1' "3 1s ."
'�ohn�l-11Sa- TI a--11 ft. rt. ASK 2 li 1UZ4
Facility/Owner Name Facility DO(If applicable))/ :
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14 g 1 v ex G1 /lk' RI' e - Vp.✓ ft. f. i Frv`:'. ? s `. ^" ;'.;:2 u
LeT �(�! ft. ft. I DWC9'3O0
Physlcgl,Addreas,Cily,a�e 1 1 - samr x :': `" :1,::-,2 ... ..'.•''4•`--.• . ..
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Parcel IdentitioationNd.(PIN.•. .
County ;
5b.Latitude and longitude In degrees/minutes/seconds or decimal degreesi • 22.Certifications
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Orwell field,one 1st/long is suffolont)
3b7'R6V N -47, 4gfV W 1/11/14 .15d/;-eit ' , .4 -Is-.11/
,, t Slgnetureot�edlaad Well Contractor U Data
6.Is(are)the weU(s) Permanent ar Temporary
By signing this foam,I hereby certUy that the wells)was(were)constructed In accordance
- 7.1a this'll-repair-to an=enistIngwoil:-4 Yee _iFigNo,-.---.__-----. --jl?lth 11ANCAC 02C.0100 or 1JA NCAC 02C.0200 Well Construction Standards and that a
. If ads fs a repair,fill out know,well bops(ructlon htformatloss and explain the nature of the copy ojtids raoord7ias been pravtdedicrtla well-owner. -
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repale under A11 re)na _section or on the back ofthls forns. 23.Site diagram or additional well details:
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8.For Geoprobe/DPT or Closed4loop'Gieothermal Wells having the same You may use the back of this pogo to provide additional well alto details or well
construction details. You may also attach additional pages If necessary.
construction,only 1 OW-1 la'needed, Ilidloate TOTAL NUMBBR of wells SUBMITTAL INSTRUCTIQN3
•• drilled:
9.Total well depth below land•sbrfacet V! (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(Q'brent(exampla•.3@200'and/ 2®100) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
((water level Is above casing,use"+" 1617 Mali Service Center,Raleigh,NC 27699-1617
IL Borehole diameters 6 4 (In.) 24b.For Injection Weliltj In addition to Bending the form to the address in 24a
above,also submit one copy!of this form within 30 days of completion of well
12.Well construction method: rotRy y construction to the following:
(I.e,auger,rotary,cable,direst push,oto.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mall Service Center,Raleigh,NC 27699-1636
/ 24c.For Water SuDDiv&Infection Wells: In addition to sending the form to
13a.Yield(gpm) I Method of tests Q-I ►' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C.h.1 d Y'l ft e Amounts ca C S completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality•Division of Water ResourcesRevised 2-22.2016