GW1--03254_Well Construction - GW1_20240528

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
e(/�� i3i1�i ai ri�j `>`l,'r 4 :r,,..ry,l �:; :,:'N`4`•' r�j`-r O..rrvi'1f POlci?j.�/•11" FROM TO DESCRIPTION
WeIlComraotorName ft, rt.
NC Well ContractorCertitloetionNumber 4,i3'iit3 11) fvt )X;J:O(f$"•tAItJNr'alfakAlfijtQ 1N)MII.'RIiAll'cllSliV:1.:
/� Pump
�j FROM TO DIAMETER THICKNESS MATERIAL
l iU►Name WL G f1 d I"U m r 0. I ft, 5 ft, ,3.126 In, 1U .1 pV G
CompenyN me Q ?}'64shro 4. t��1 'i7Vonem 7 6'IliWkj)1 4fIffthliYik*q-�,:ir:ir�., <.
SW 2 3/2LI — C 1 5 FROM TO -pIIAMETER THICKNESS MATERIAL
2.Well Construction Permit ifs ft, rt, In,
List all applicable well construction mad!:(Le.U/C,County,State,Variance,etc.)
ft. ft. In,
3,Well Use(check well use): , {" �,: ,y ii:;',:r's-?S's .u.r:;r,
=fn}►g�1i� l;131~::�''.;�iri,3.,�yt�,stj4Y,�!i,� k:rs•7�'ifr~�. � �.
Water Supply Well: FROM To L 1RTER atoTSlzE THICKNESS MATERIAL
Agricultural DMunlolpal/Public R, ft, — In,
(single)
rt. It. In,
Geothermal(Heating/Cooling Supply) �Rosidentlal Water Supply � .
Industrial/Commercial �Residontiel Water Supply(shared) "a84(l,,�i .fi r��Ftf;rr;:, ps+f(iLkis tf fr+ ,c+,,s%;3`;(_'`t,''',1''`,;,;r i r` ;:; '..r.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lon ft. 20 rt. . ,I I 0 tt3aq, C
Non-Water Supply Well: 0
Monitoring DReoovoir ft, It.
Injection Welh rt. ft.
Aquifer Recharge Groundwater Remedletlon r ,;; ,:;;t <5�'::;;<';;+
f9,7,$Atl�lrRAL':P�S�I (tip#t1c4�I�TM. s ,. r
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL •
EMPLACEMENT METHOD
Aquifer Test
DStormwater Drainage It, it,
Experimental Technology • '� OSubsidenco Control It, It,
t[-���f},Tracer ill)I4 t VII3, 1l : UaEt'a i' tifilllonaiiilati fi li'a brill is; .;;r`:;.
Geothermal(Closed Loop) t PROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under fill Remarks) 0 ft, A 5 rt. clay L
4,Date Well(s),Corhlileted: J-13 -2 Li Well ID# • 26 ft. I 96 ft. r?ran 1 7•G
IL ft.So.Well Location: It ft.
I Zrt15 G Alin Cra 1gCr. • • ft. rt. T
Facility/Owner Namem /, �/Faultily/ ID#(If applicable)
, 1
3� I 014-c, PO -t i d (Lakt Lure ,,444.•I, o+), / ft. ft.
Physical Address,�I:y,anddfZip / p ) 3.,.: _.. .. `
'(i1)�V t.J ;'t$��� I�&���'>;1�':r%`ts%<'; 'v"•.?:'.� 'i��
County Parool Identification No.(PIN) -.
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi ; 22 Certification:(If well field,one let/long Is sufllclont)
5.1-1772? N — Sz.l°Sq 5 W �40t.(.- S.:—if iZ�
t Slgrietureof.�ertlfled Well Contractor Pate
6,Is(are)the wetl(s)aPermanent or Temporary
By signing this form, I hereby certify that the we(((sJ was(were)constructed in accor•danc+
7.is:htc«repot:to on existing well: DYes or ligNo ' with/54 NCAC 02C.0100 or/SA NCAC O2C.0200 Well Construction Standards and That r
copy sljth/s record has base provided t�the well owner,
Ulhls is a repa(r,Jl(!_oul known well borystructfon information and explain the nature of the 23,Site diagram or additional well details:
repair under#2)reinarks_reciion or on the back of this joint,
•
You may use the book of•ihls page to provide additional well site details or wet
8,For Geoprobe/DPT or Closed=Loop Geothermal Wells having the same construction details, You may also attach additional pages if necessary,
construction,only l OW-1 Is needed, lhdloate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled;
9,Total well depth below land surface: 1 9 B (ft.) 24a. For All Weller Submit this form within 30 days of completion of wel
Far multiple wells list all depths(/'d(O•ereut(example.3®200'and 2gg1100') construction to the following:
10,Static water level below top of casing: LJ 1 (ft.) ' Division of Plater Resources,Information Processing Unit,
if water level Is above casing,use"+"� 1617 Mail Service Center,Raleigh,NC 27699-1617
// in
11,Borehole diameter: ( (In.) 24b.For Infection Weiji: In addition to sending
n 30 oof othe add ress
24t
•I above,also submit one copy of this formdays
12.Well construction method: bTAY 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
Method of test: �t`r For Water Suon;iLIS infection Wells: In addition to sending the form t
13a,Yield(gpm) �IQ 24c.the address(es) abovo, also submit one copy of this form within 30 days c
Gh�a ri�� Amount; completion of well construction to the county health department of the count
13b,Disinfection type: where constructed,
Revised 2.22.20I
Form OW-1 North Carolina Department of Environmental Quality•Dlvblon of Water Resources