GW1--04594_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: iMEMINN
1.Well Contractor Informatlon: •
(�X J +r-\
Well Contractor Name 10�
4 5 t q -A 0 0 ft• c t s ft. c-&4, Ce--� \O0 3-Pur)
n. ft.
NC Well Contractor Catibm Number
o ,,,"( V1 0.\dI.JQ b,.` • 1 i,
t 1 It• PROM TO IL 1t. t Ia THICKNESS MATERIAL
Company Name S V �11P c � P v �-
2.Well Construction Permit#: O 9) -3 k 3 J PROM TO DIAMETI a TRIMNESS MATERIAL.
List all applicable well cassauctlon penmitr(i.e.UIC,Coney,State,Variance,etc.) ft. ft. fa.
3.Well Use(check well use): ft. in
Water Supply Well: =GM TO DIMMER SLOTWM TRICENZas MATERIAL
a Public ft. ft. tit
(Heating/Cooling Supply) ! Water Supply(single) ft, fr. ' its.
Ind ial/Commercial OResitiential Water Supply(shared) .
kri r't,i6on FROM TO M:21AL ti •�...$ I+ sacrumi A1d
Non-Water Supply Well: (; ft. ft. Qbtl.C -TC . • S R - S®
Monitoring ()Recovery ft. .
Injection Well: NI t = �'
ft. ft.
AquiferRecharge DCaotuidwater Remediation
Aquifer Storage and Recovery QSalinity Ratner FROM TO MATLRIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage ft. ft.
ExperimentalTechnology DSubsidenc a Control ft. ft.
Geothermal(Closed Loop) DTracer
Geothermal(Hating/Cooling Return) DOther(explain under#21 Remarks) FROM TO (actor,hardness, type,twain the,ate)
4.Date Wdl(s)Completed:'1 a 4` Well ID# ft.• 1 0f OD C .i,n ` ,
5a ell Location: Q 1 a v ft. e a, L 4 t C Q - ( z O 5 t fir''\
Faces, •N Fes,IDS(ifapplicable) ft. ft.
Ibt&A'-rkd • z.�tcco`,a �C ft. ft.
Illicit Address,City,and Zip , f . .. _
TA rs4 SilAkei
V1 4 5
County Parcel Identification No.(PIN)
Sb.Latitude and longitude ht degrees/minutes/seconds or dedmal degrees:
(dwell field,one s sufficient) 21 C te[ ")
�- a ��� � ji� ' a 4—
6.Is(are)the wen(s)QPermanent or rkemporary s' of Certified Well Contractor
By signing this fora.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Q 'o with 1 SA NCAC 02C.0100 or I SA N:.AC 02C.0200 Well Construction Standards and that a
If this is a rep®,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well owner-
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER o - construction details. You may also attach additional pages if necessary.
drilled:
\ 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of
For multiple wells list all depths U.diff rent(example-3®200'and 2®100') construction to the following: completion of well
10.Static water level below top of cuing: L C (ft.) Division of Water Resources,InformationProcessingUnit,
1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole dlttseter: ) 24bFor Infection W
I& In addition to sending the form to the address in 24a
12 Well cons uetlon method: t) rl r above, also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,able,direct push,etc.) construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,
c Raleigh,NC 27699-1636
13a.Yield(am) \ 0 0 Method of test: Kt ) 24c.For Water Sanely&Inieetion Wells: In addition to sending the form to
0'' the address(ea) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �N Amount �- completion of well construction to the county health department of the cry
where constructed.
Form OW-1 Not*Carolina Deportment of Environmental Quality-Division of Water Resources Revised 2-22-2016