GW1--03013_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: �L
1.Well Contractor Information: •
reArty
Well Contractor Name FROM TO DESCRIPTION
ft. ft,
2.136 A ft, ft,
NC Well Contractor Certification Number ;i:$i�d m�ji`,,0I i(T'o"��Ij it"�� ��yel(i)i; 'tfjj }j�f(jfpj(piiciHliy)%::.;. •
FROM TO DIAMETER THICKNESS MATERIAL
Cams Well cold Po pi p Co. ft, tqG rt. 125 In, sog A.I �pv6
P Y
Com an mo {,� �y^�Q� 7 �]�?fl�l`IgR4(�StiClA�Ii" l�t�ft`��o'(tIb'lsdii ;414Deli�.tipl'g:'a;j-':�i::.';_:;,::`
2.Well Construction Permit Ii: EH e 2 J : 6 / -FROM TO DIA:NETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc,) rt, rt. In.
3.Well Use(check well use): ft. ft. In
i'f.7ts t. li.i52a'#:•e'''i'1','th v7.:'lf7'ra.<<-'?J,w., •;:. ..,.', - :::..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunioipaVPublic ft, ft, ia.
Geothermal(Heating/Cooling Supply) itResidential Water Supply(single) rt, ft, in.
IndustriaUCommercial DResidential Water Supply(shared) (.sits ovt, ;; y,f; ;y ei3Oogrh ,., t r±*M' s x :..•i
Irrigation PROM TO MATERIAL EMPLACEM TMETHOD&AMOUNT
Non-Water Supply Well: 0 rt. �,Q I. 0,4t�;Q r , 10 1 Jc .S
Monitoring DRecovery ft, ft. v
Injection Well; ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery ' OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O'Stormwater Drainage ft, ft,
Experimental Technology -..‘,t Subsidence Control it. ft,
Geothermal(Closed Loop) OTracer T IVI 11'1t,61T,0:0((a'Ef7el1`P.df onaihhee'tWi eesai•(0):.:;,:.,'.;i=;;,, , -;:c"
Geothermal(Heating/Cooling Return) Other(explain under:Y21 Remarks) FROM TO DESCRIPTION(color,hardnese,solVrock type,grain size,etc.)
0 ft. lob; ft.
4.Date Well(s)Corht,leted:' —I—A !u Well ID# . to 1 ft, 105 ft. it rY Ylt-ft
5 ell Location:i ft. ft.
Vat)l 4 Jto15on ft. ft.
•
Pacility/Owner Name Facility ID#(If applicable) ft. ft, '..Y 2 ,
2.0 No rn t A d. ft. ft. _
Physical Address,l City,and Zip rt. ft.
pOi
„0„-.„,,,,..s:,,,-„,..„„,„.4.-„,„,,...,.,,...,,,„•.,:::::„:,,,„:„:„.:.„:„.„... •:: .- --.•..-:-:. ,
County Parcel Identification No.(PIN) -
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees: ; '
(if well field,one let/long Is sufficient) 22.Certification:
35. 23156 N —8'2.0693 ) W Det,t �w h l� ,/y
Date
6.Is(are)the well(s)4IPermanent dr jTemporary Signature of Certlfled Well ontracio�(
By signing this form.:hereby certify that Ms wells)was(ware)ca,ss:rricted in accordance
7.Is this a repair to an existing well: QYes or *No with ISA NCAC 02C.0100 or iSA,VCAC 02C.0200 Well Construction Standards and that n
If Iliis is a repair,fill out known well construction lq/ormation and explain the nature of the copy oftlds record has been provided to the well owner.
repair under kit rernarkr_rectton or on the back of this form. 23,Site diagram or additional well details: •
8,For Geoprobe/DPT or Closed-Loop'Geothermal Wells having the same You may use the back of this;)age to provide additional well site details or well
construction,only 1 OW-1 is needed. Ihdtoate TOTAL NUMBER of wells construction details, You may also attach additional pages If necessary.
drilled: ,',)
(� SUBMITTAL INSTRUCTION
9.Total well depth below land surface: /�,�///rr,,,5 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3200'and 2@l00') construction to the following:COb
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+/"+ 1617 Mall Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: f/1 (in.) 24b.For Injection Weill: In addition to sending the form to the address in 24a
L above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: t-If11 ot✓y 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 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 1 6 Method of test: 4r r 24c.For Water Supply & In : r . : In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Chior rl(, Amount; S completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality•Division of Water Resources
Revised 2.22.2016