GW1--03196_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only: —
1,Well
(y'�y�\'ntractoor/In^ffe rm(/attJ1flt • J i��yj,/{�• ryy� •
Y. V / i �/✓`�',�^ -- 44;I,nl�i.W. fiW;�'..VA'1,;!tt:V ....F,i:: y.: ..i, ;'.. .:•. .
J /I ul� FROM TO j DESCRIPTION
WellContreotorNzamo / ft. ft,
2-13 ft.
NC w 1!Contractor Cenitloatl n Number =1104tlI R�'A' P Y(t ` g3 ' 41° tii ' uri
EREMMINNIMI
�1 l 1 p FROM TO DIAMETER THICKNnESS MATERIAL
ny S !/1/��I / � � C�(J �� {�� � tt. G , �5 tn, 5p l`Company Nam/ 461?id'At61' rdk , i`.01. `alIL It JFrif.ti 3MMENNIge
f7 ill:,
E TO )�ME ER HfCKNE98 MATERIAL
2.Well Construction Permit#: Vi/e.)/' /I �s`D �J 02a'7 '`� ft, tt. In,
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) In,
3.Well Use(check well use)t ft, ft.
;1htl3.Qlti ! �',?n',;�fi),,. , yr, n'•�:r, ,:,(z,.y;•;s;.+;,,t?i.:a..::.t.:.:;
Water Supply Well: FROM TO DIME8L0 81Z' iCKNE88 MATERIAL,
.(.
( Munloipal/Publfc rt, ft, In,
•Agricultural _---
Geothermal(Heating/Cooling Supply) EResldantial Water Supply(single) ft, ft. i"
Industrial/CommercialDResldentlal Water Supply(shared) N1�IIito fC7rt>)�;< '�ls, '=:,:,;;�'a i l �i+s';;a} ",;;,r;";,<;<;;; l,:r??';s.:�rn:,'3::.',. ,.:
FROM TO MATERIAL EMPLACEMENT METHOD'St AMOUNT Irrigation Q "' ,. ft, ,e_i. ') E •— Id4-
Non-Water Supply Well: ft ft.
Monitoring 0 ,Recovery -
Mil
Infection Welll ft, ft.
Aquifer Recharge ©Groundwater Remedlat{on 'sf�h�9ci`lp)rR%���rI'tRA KD�• al!11 UJs r,, ak. ...,. . ,lYli%:1i': >::, . :: .
' , �15{'� EMPLACEMENT METHOD
•
Aquifer Storage and Recovbry 1Saltnity Barrier FROM TO MATERIAL
)�`� LjStorrnwater Drainage ft, . It,
Aquifer Test "'
ivtu Subside Control ft, ft,
Experimental Technology ,� l;zX0„'j�0131r§lb;t;;b:0i(t+tL P)1 .tanalL ` O "' 'I ��
Geothermal(Closed Loop) Tracer FROM TO DESCRIPTION color hardness solltrock .e •rein elze etc,
Geothermal(Heating/Cooling Rotum) Other(explain under#21 Remarks) b ft. C1 a ft. 4-i v t, c�1 a_y
�coC-�"T Weil ID# ! tt. ��U ft, _ rxYL( .{�'
4.Date Wel(s)Cokiletedt / ft, ft
5a,Well Location; • t, ft.
7Zm r a- S t c-fto� r ft. rt.
Facility/Owner Name f // 1 Facility IDN Mai II(Ifepplloable) ' 27".11. 1
Physical ddr°ss,City,and Zipj1-'/ riz:;fhtlES;<`n: ' i': •`'Y'
County Parcel Identification No,(PIN) -.>
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi., 22.-
Certification'
(If well field,one let/long long Is auftiolont) i ��
Dat°
�7`777 N 41, bbb3 w �I -le .
Signature of.Qertlfled Well Contract()
6,Is(are)the well(s)�Permanent ar Temporarythe well(By signing
it U•NCAC 02C.0100 er/5.1 NC,4Ct 02C 0100,Well Cons!ucllon Slandatl ds and A tea
e
7,Is this a repair to an existing well: QYee or ffiNo • copy of this record has been provided to the well owner.
Uthls is a repair,Jill out known well bopslrucllon information and explain the nature oldie 23,Site diagram or additional well details:
repair under 421 reinaekrsection or on the back of Ws form,` You may use the bank of this page to provide additional well site details or well
•
c,For Ceo ,o 1 O or is n ed ed. Il dlo to TOTAL
Wells ng the samellsconstruction details, You may also attach additional pages if necessary.
construction,only l OW-1 is needed, Ihdloate TOTAL NUMBER of wells �r,BMIT'CAL�YNSTRUCDONS
drilled: � `
9,Total well depth below land sut'facer ,Z —(ft') 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths[d( sreul(example-3@200'and 2 I00') construction to the following':
L�j (ft,) - Division of Water Resources,Information Processing Unit,
1
([water
water level below top of casing: 1617 Mall Service Center,Raleigh,NC 27699-1617
11,Borehole level Is above casing,use"+Y'-'i
!DpnJ 24b.For Infection Well@t ]n addition to sending the form to the address in 24a
11, dlametertabove,also submit one copy of this form within 30 days of completion of well
12,Well construction method: r o ' -Y / construction to the following:
(I.a,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLYs I
13a,Yield(gpm) � t y� 24c,For Water 1DD)v �,•Yniection Welist In addition to sanding the form to
, ! f Method of teats the address(es) above, also submit one copy of this form within 30 days of
G>1 brl Yam_ Amount: U. completion of well construction to the county health department of the county
13b,Disinfection type) where constructed,
Revised 242.2016
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources