GW1--03903_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
( Well Contractor Informations •
l/L'ttrr't Paclei,P/ PROM IfUIZ. ToDESCRIPTION'
Well ConlrectorName U ft'
L1514 5.A fft.t R.' ft,
NC Well Connaotor Certification Number ':d;t3�;Ot)m�k�0'AS) T{�Y(f '(i+it1Jif t, 'e.l•�1 t's;r_ N,•,{ '`t:Ilc�tili H
ectvl DIAMETER AT
THICKNESS MATERIAL
I�/e)) a n.d Po I}'L Co i FROM TO AT /
fL 0 0 ft. 6.li In, 5042 I f v
Company ame t}o)15t11T1ti riN °d ' tf; :o t' ,)Mo..".' lY
t_ M 3/7/1 OS I v� FROM TO DI/.M'5TER THICKNESS MATERIAL
2.Well Construction Permit#s (1/n( �C'1 V �! Cl, H. In,
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) In
ft. ft. _
3.Well Use(check Well use): ;fhN,g'9 t `3if�''' n;�i•irryt>� >t s; ;t'EtFn�+:j w'�;/'^t!`i?:.;nC '.r f ;
Water Supply Well; FROM TO DIMMI TRR SLOTSIT.Z THICKNESS MATERIAL
DAgricultural OMunioipat/ ft. ft, In,
Public
OGeothermal(Heating/Cooling Supply) oRosidential Water Supply(single) ft. ft, I",
P b v>>„' 4si�r t,e 1,}Y.i c .;.{•,?;:t);Ft 1)y`.4?:;'.
�"',-,p,IndusttlaUCommercial DResidentlal Water Supply(shared) )'$(t6Yti((1 ;,, ,IT?;.,;A.;r(;Ih, z��,,(rrrr
FROM TO M,ITERTAL t EMPLACEMENNTTTMETHOD&AMOUNT
Non-Waterotl O ft. �Q ft, 13cAlt Q•r,C I y +�U(yam
Supply Well:
Monitoring Recovery rt. ft,
Injection Weill ft, fA
Aquifer Recharge Dt3roundwater Remedlatlon ;i.9,hf?�'1 D�iRA'.I fiI fPAf�iC111(k9dizltaU�1>0 .x . '^',; ' ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATP�L
EMPLACEMENT METttOD
Aquifer Test
�' [ Stormwater Drainage fL ft.
ns';'. Subsidence Control fL fL
Experimental Technology w:,k• O
i';t0 aTtItt?I'fill;OCit(titt'VFlNEUT 7ailihc liil`fiN>ooctiiti'L;.;. ;%::'.:. .. ,.:
Geothermal(Closed Loop) �Traeer PROM TO DESCRIPTION(color,hardne n,notUrock type,grata rite,etc.)
Geothermal�Heating/Caoling Rotum) 0Othor(explain under#21 Remarks) O it' I ).,0 rt.
4.Date Well(s)Corh leteds 6'6 aC Well ID# a ft' 665 fL s7r""t ` t'
5a,Well Location; • ft, ft.
t. L
Cti1li 140) S ?024
Facility/Owner Name Facility ID//(If applicable)
SW Old MoO shorn Ad JYIOtovrisboiv . ; :Atli
Ph steal Addrwe, ity,end Zip t ft, It, `' i V.',;$,`v,.,,.
9!3:I::��h�tA�lfiB:,,:1 :r.�s.
,u >�i rd
County Parcel identification No,(PIN) -.-
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi 4
22.Certification:
well field,one lat./long Is sufficient)
35n),. /0I N II,761 W d A% - i�- �l
t � Dale
Signature of.�ertlfled Well ConU•acto
6.Is(are)the Well(S) PSrmaneDt dr Temporary By signing this focus./hereby cerl,fy that the well(s)was(were)constructed In accordance
with 1SA NCAC 02C.0100 or1)A NCAC 02C,0200 Well Construction Standards and that a
If Is this a repair to anexisting well; cr *?s copy of this record inns been provided to the well enact.
Ulhls Is a repair,Jlll out known
own well Consultation information and explain the aerate of the Site diagram or additional well details: •
sepals•under Hl1 remarktsectlon or on the back of thts fornI.
23
` You may use the book of this page to provide additional well alto details or well
8,For Geeprobe/DPT or Closed-Loop Geothermal Wells having the same eonatruotlon the
l . You may also toattach r vide adds pages If necessary.den
construction,only l OW-1 Is needed. Ihdloate TOTALNUMBER dwells 6 ,SUBMITTAL INSTRUCTj,Ql�
drilled; ,, (
9.Total well depth below land surfaces •v 6 (ft.) 24a, For MI Welit: Submit this form within 30 days of completion of well
For multiple wells list all depths(/•different(example.3Q200'and 2®100') construction to the following:
10.Static water level below top of casing: C2 Q _(ft.) Dlvidlon of Water Resources,Information Processing Unit,
((water level Is above casting,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameters CJ (in.) 24b.For Infection Welly: 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: 0 y ltr U construction to the following}
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mall Survlce Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
)
13a,Yield(gp
1 Method of tests 24c,F91'.2Wat11er Sunply d Irtlectlon Well,t In addition to sending the form to
m t I' the address(es) above, also submit one copy of this form within days of
C11IO►^1 r){, Amount: 2 U S completion of well constriction to the county health department of the county
13b,Disinfection typo: where constructed,
Revised 2.22.2016
North Carolina Department of Environmental Quality•Division of Water Resources
FormtJW•I