GW1--03257_Well Construction - GW1_20240528

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: —
1,Well C tractor Information:
Ittf
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( � FROM TO DESCRIPTION
Well Contractor Nema ft. ft,
NC WeU))ConnactorCertifloatlon umber payrz70
;f.>3�bt1)11b)° �At$IYI0,((ol~f`i1(}�c Cdl.W�113j5Q � IN 't(I it llc�HtSl/n cI1FROM TO DIAMETER THICKNESS MATERIAL
/Lny / f rt. 6 y rt. ,,t2 5-in, at P yc- .
Company Name ?�bt.fl NEiI;'. A81N i(QIY, (�olli0in1 r�l4�etllr pifP ' J , ,.
� i - f - O S '7L FROM TO DIAMETER THICKNES9 MATERIAL
2,Well Construction Permit#: 0� 7 �[ !!! fL ft. In,
List all applicable well construction permits(i.e.WC,C unty,State,Variance,etc)
ft. ft. in,
3.Well Use(check well use): r t x''''�� r '4+1i7;;rkn l 1J J r ',
Water Supply Well: mom TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft, In,
Geothermal(Heating/Cooling Supply) -Residential Water Supply(single) ft. ft In.
IndustrieUCommercial 0Residential Water Supply(shared) 11!('b1i417t+#5s l,t y;,v,y4(t�• 0s.7fF,�,let ��,. ' ;, nW `r -:'
FROM TO HATE AL EMPLACEMT METHOD&AMOUNT
. Irrigation _
Non-Water Supply Well: U ft, :) ft: ��,�i� il i-e_ pU�V - /,1 C�,CC{'.
Monitoring OReoovery ft. it. — _ �J
injection Well: rL ft,
Aquifer Recharge 0Groundwater Remediation i49: 810/.0RAVittPA`$,K 1fOitlfilicglil¢),'!'& t. • .
Aquifer Storage and Recovery ' OSalinity Barrier FROM (t TO ft. MATERIAL EMPLACEMENT METHOD
Aquifer Test `. [ Stormwater Drainage —
Experimental Technology .`,,,, DSubsidence Control it, ft,
-�lTracor I11',4 ,,ii t)1�I" i),,d'Qi(Pft P�;$lIaltici a11ih'e6tgj► 141Sat,, .
Geothermal(Closed Loop) f ,r FROM TO DESCRIPTION(color,hardness,wlUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D ft, q' ft,
4,Date Well(s)Corhpleted: "02d),-2-4(reli ID# 70 ft' / 5". r a'K(
rt. ft. L�
Sa,Well Location:
1, ok .
Paolllt IDS(if applicable) ft, ft.
Facility/OwnorNpat5 mo Y —
Physical A dross, y,and Zip yr ' .. ,r'. .. 't)ti} ;%i-:Y,:
County Parcel Identification No.(PIN) -.
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi ; '
(If well field,one let/long Is sufficient) 22.Certification:
w 4,,/ z_d/vi--) ') .. .--- /7----, 4
Signature of.Certlfled Well Coatmct Date
6.Is(are)the weU(s)ePermanent dr Temporary a"y s4ni.,g this jc,,u,I hereby Ce:':y� .,h_.a:the_e we!/(r was(were)constructed in accordance
7.Is this a repair to an existing well DYes or 11)No with 15A NCAC 02C.0100 or ISA NCAC 02C,0200 We!!Cortstructlon Standards and that a
if this Is a repair,fill out know,well copsfuctlon War/nation and explain the nature of the copy of this record has been provided to the well owner.
repair under Oil reinarkssectlon or on the back of this form. 23,Site diagram or additional well details:
You may use the book of this page to provide additional well site details or well
8,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 OW-I Is needed. Ihdloete TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
,SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: I 0 (ft.) 24a. For All Welly: Submit this form within 30 days of completion of well
For rnaltple wells list all depths(fdi different(example.3®2 'and 2QI000 construction to the following:
10.Static water level below top of casing: (Y b (ft.) Division of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
if water level/s above easing,use +"
11,Borehole diameter: 6A- (In.) 24b.For Infection Wells: In addition to sending 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: '61;Y)I construction to the following:
(Le,auger,rotary,cable,direct push,eto.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm)
/d Method of test; a-i V.' 24c.For Water SuDDIv &Infection Watt In addition to sending the form to
J f c the address(es) above, also submit one copy of this form within 30 days of
e ck l o Y./VLE- Amount; ) G CC( completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22.2016