GW1--03828_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only: —
L Well Contractor Information: •
Goiy/Ovi �GUlq �.,l9!$�1Tixo rfT.S�tDEB RIPTION ry i.l'':... . .•. .. `
.
Well Cctor Name FROM fL tt,
(1636,4 ft, —
NC Well Contraotor Certification Number C _fl`,Y`lu EP ISTII 1i� li13�' 0 IAM
ENIIIINE
Co S f�P !( aid Pomp i'7� PROM ft __c� DIAMETER In THICKNESS MATERIAL
Company Mame I;tIMt uYSIR[?t IOR 11.0)?421l'1' RIEBI
u �� ,I.0• •R = MATERIAL
2,Well Construction Permit#: Y)/a °
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft, In,
ft, ft, In,
3,Well Use(check well use):
Water Supply Well; r e, �� DIAmE E IN THICKNESS MATERIAL
Agricultural OMunicipatfPublic ft. ft, In,
Geothermal(Hoating/Cooling Supply) £Residential Water Supply(single) ft, ft, in, •
Industrial/Commercial [Residential Water Supply(shared) mumje',kh;g.,.,v:::i<.; -4,•IA� '41+:-.fv.,tw•,,'rv;"r,:....,,N;0!r'•"ti..'°> .:_:
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' MI f.•i i. •oh'G 10
• Monitoring DRecovery ft. ft, —
Injection Well: fL fL
Aquifer Recharge ]Groundwater Remedlatlon � MIDIM�;1Zra:EYa TRIM M or;;`;;, r:: f. 'i,,i:: ,q: ',:••. .:,
Aquifer Storage and Recovery Salinity Barrier f[Y•R:reCe u a!A /L1L° Jx SIATERI L EMPLACEMENT METHOD
Aquifer Test %"‘:. roStormwater Drainage ft, , ft,
,v,. Subsidence Control ft, - ft,
Experimental Technology �.;; [� ,..
s r r5f•i a s s ;•/,•••.:.
Geothermal(Closed Loop) Tracer I IP Z -1!1 r4d DESCRIPTION tPl fit`T s l „ •
•� TO color hardness wlUr°ck n •ruin size tic.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft, ay
4,Date Well(s)Completed;c-D`2 Lj Well ID# . MIL 5 ft. t,%r(Y h 1fe..,
ft. ft.
5a,Well Location; ft. It. ' ..'►..: V C
, ;vntiC,�-bins, noludie, ft. ft. t `)
Facility/Owner Name Facility ID!!(if applIcable) �LN 9 8 ���
• 756J V' ►0i -�d P..
rt. ft. !rfdrMG.: p..r _,,
Ph slcel Addrort,City, Zip
i�rk-Q
County Parcel Identification No.(PIN) —
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi ' —
(If well field,one Iet/long It suffiolont) 22.Certification;
35. 601-I5D N —$'I, 525g6 W -/ , 6 ' 17-A-
Signature of ariltled Wo I CQ rector Date
6.Is(are)the weU(s) Permanent dr Temporary
By signing this form,1 hereby cert(!y that the weli(sJ was(suers)constructed in accordance
.i h 11A NC4C 02C.0100 at.ISA NCAC 02C.0200 Wel!Construction Standards and that n
7,Is this a repair to an existing well:nstrYes or No copy of this record has been,vrovided to the well owner.
If this is a repair,Jili out knornt well Construction h(/brmarlon and explain the nature of the
repair under RI reinarkraerHon or on the back ojlhlsform. 23.Site diagram or additlonal well details: •
8,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the book of this page to provide additional woll site details or well
construction,only 1 OW-1 Is needed. Indicate TOTAL NUMBER of wells
construction details, You may also attach additional pages If necessary.
drilled: SUBMITTAL INSTRUCTIONS
9,Total well depth below land sur /'face: fJ 5 (ft.) 24a, For All Welly: Submit this form within 30 days of completion of well
For multiple wells list all depths(/'d(/J'ereut(example.3 200'and 203/00') construction to the following:
10.Static water level below top of casing: t'l c) (ft.) Dlvl9ion of Water Resources,Information Processing Unit,
I'water level is above casing,use"t" 1617 Mall,Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: G (in.) 24b.For Infection Welly In addition to sending the form to the address in 24a
• above,also submit one Dopy of this form within 30 days of completion of well
12,Well construction method: 010411 'Y construction to the following:
(i.e.auger,rotary,cable,direst push,oto,) / Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY; • 1636 Mall Service Center,Raleigh,NC 27699-1636
n /4;Y' 24c,For Water Suppl'�S4 Infection Welly in addition to sending the form to
13a,Yield(gpm) d}���"`` Method of test; the address(es) above, also submit ono copy of this form within 30 days of
I./IIU►^1 Yi L Amount: o- ���s completion of well conshuction to the county health department of the county
13b.Disinfection type: whore constructed,
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22.2016