GW1--03465_Well Construction - GW1_20240611

l.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information; •
4 tIjctt FROM TO DEBCRIP,J'ION
Well ContraolorNsme ft. ft,
NC%Ii Contractor Cenitioetlon Number �
1d(;�. 1) 4� �e SiX9Y(t ``IltRt7IE ! liiitOR 1N4fif ii'llb�dt i::: ...:
� /� PROM TO DIANIE9'ER THICKNESS MATERIAL
'L 5" � �' ��GCIn (i0,i l�(G, i ft, 4, ft , /�yX5- In, SUK 1 �J i/�
Company Na /� }d el' AMOR' t6u61i't )i�lQ�etl°sY11ii':i.v,"�•t/Jra.'... ,.;:. .< ... ..
li �—�D3 G FROM TO DILErER THICKNESS MATERIAL
2,Well Construction Permit Ill ! ll II ft, rt. In�
List all applicable well construction permits(Le.UiC,County,State,Variance,etc.) — In.
3.Well Use(check well use); ft, It.
y uti:' �' It;r,. tt, ?iy Ki`.tti�r:�w ! ,+•::',;'a;c�::;irr<;, `,
Water Supply Well; ••O 0 DIAMETE 8L0 8 Z' THICKNESS MATERIAL
Agricultural [DMunioipal/Publio A. re, tn.
Geothermal(Heating/Cooling Supply) %:.''RosidonNel Water Supply(single) ft, ft, In.
IndustriaUCommerclal DReaidentlal Water Supply(shared) matioruz,5, I vie ..`c'n, -.; ; ,' y,.i: _,;;.`-,.. ..='//"''' , 0•.'a
,;Irrigation FROM !t TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1
MonitorIng [Recovery it. ll —
Injection Well; ft, •
Aquifer Recharge 111 Groundwater Remediatlon : .y,y .;� I)l,.)tAY'LiPAe r 161i711�:r•r'k ''-t S •:'"`i ": '
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATBRiAL
EMPLACEMENT METHOD
Aquifer Test ).'s; LarlStormwater Drainage ft, , ft.
Experimental Technology ,"\ OSubsldenoo Control ft. - ft.
Geothermal(Closed Loop) OTracer I;- Ol')yTtllikli0bi;p: i(p'ttYO'liAtiig90slllheil`gif(i)iiella s F;7.;l::''
FROM TO DESCRIPTiON(color,hardnese,loll/rock type,grain nee,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft, Li ft. Lti y t Gi Ni
4.Date Well(s)Corhltletedt IT-36-_.XL/ Well ID# 'h ft. ��5 ft VG(/(i.1-a.,
ft, ft.
Sa,Well Location;
�.l� � '1 �L
- rt. ft. •
��-�`����1 / l M ACC L� JUN j 1 2 0 2'� •
Faollily/Owner Name Facility IDII(If applloable)
ft. .
ft, ft, lrio'rsi?+1r Aeorilq Ur,6
.�L' R CJ, i\l•�rt. a) l-��.Xe er ft.
Lit )4- lm ic. .
Physical Addrwa,Clty,and Zipt ..:A..:: ; _,'it' •• •,: ..
County Parcel Identification No,(PiN) -.; `
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi —
22,Certifications
(If well field,one IeVlong Is sufficient) �C��C. -3 4��92- N —4Z, ,D(,LiI-3 w ' %_� ``i Co—
l Si eturoof.Qertllled WellContraoteS% Date
6.Is(ars)the weli(s)SParmanent or Temporary
By signing this jot,,/hereby ec110,that the we!l(s)was(vere)constructed in accordance
7•Is this a repair to an existing wells D,'Yes or lioNo • with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
IOW is a repair,JNl out known well Construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under h11 reinarkrs_ectlon or on the back of this form. 23.Site diagram or additlon,al well details:
•
You may use the book of this pogo to provide additional well site details or well
8.For Geoprobe/DPT or Closed=Loop Geothermal Wells having the same also attach additional pages If necessary.conelruotlon details, You may.
construction,only I OW-1 Is needed, IJidloate TOTAL NUMBER of walla
drilled: � SUBMITTAL INSTRUCTIQL`
9.Total well depth below land surface; `7 (it,) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(!d(Q'erens(example.3®200'and 2®100) construction to tho following:
10.Static water level below top of casing: (ft.) - Dlvidlon of Water Resources,Information Processing Unit,
(/water level is above casing,use"+'�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter' C� A- an.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
{ r/ above,also submit one copy of this form within 30 days of completion of well
d'1� • construction to the following;
(I,o,auger,rotary,cable,direct push,ate.) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY; • 1636 Mail Service Center,Raleigh,NC 27699-1636
I a Method of test; a r Waer SuD1
ir 24c.Fotnv & Infection Wells; In addition to sending the form to
13a,Yield(gpm) the address(o) above, also submit one copy of this form within 30 days of
( / t{ Amounts / G(_ �_. completion of well construction to the county health department of the county
13b,Disinfection type: L where constructed,
Ravlsad 2.22.2016
Form OW-t North Carolina Department of Environmental Quality-Division of Water Resources