GW1--05009_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
/! 4- 6"it Pa-(I e 14.::VSrA1E(t`ZONI4 . '',- :.'
RIP
FROM TO DESCTION
Well Contractor flame _ ft. ft.
C 56 R ft. ft.
NC ell Contractor CcrtifJ11/, L
lion Number 1'S,;Ot1oR_CA SINQ'{foranu►H.$esCihw¢)If):Olt'$Ij1$) (It;ap llegtile)
FROM TO DIAMETER 'rI1ICKNESS MATERIAL.
✓� • ��{l� CD,/.�LG ' I ft. �Cr ft. 6, 1 yZ.Ein. 5'viz.7) V r{
Company r� � / 1,6r' . .
( / g� INNER CA51NC3 OR 7.IJIFTNMETeotb�I mil sl ICKN eon)' ,
2.Well Construction Permit#: FROM TO DIAMETER TnICKNIM MATERIAL
List all applicable well construction penults(i.e. U/C,Count,Stale,Variance,etc.) ft. rt. — In.
3.Well Use(check well use): ft. ft. In.-
17t SCR N-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©MunioipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) .f j.Residential Water Supply(single) ft. ft. In.
Industrial/CommercialResidential Water Supply(shared) le,GROUT s •.
IrTlgation PROM TO MATERIAL EMPL.ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: D ft. <,.0 It. )art`}-en;to pDlAi/P-c- - 42- (6G5
Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge inGroundwater Remediatlon •19rSAND/GRAVEI;PACEN::applicable).''
Aquifer Storage and Recovery OSaiinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage it. ft.
—
Experimental Technology DSubstdence Control • ft. ft.
Geothermal(Closed Loop) OTracer ;P;,DRILL,G 1.OG,(atkc .arlditIontiLsheets+iftec'etspry);
FROM TO DESCRIPTION(color hordorag,gal Crock pile, ruin du,sic.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
!!ll ft. �-q ft• i r7�r G'1`�yi 5 a S v n
4.Date Well(s)Completed: l'-O"--2'7" Well IDN 0 ft. D�(t. Ydt I')I �(�
ft. ft.
Sa.Well Location: }
• S' y/i ! Ie_ — /' l ft. ft. .
Facility/Owner Name FacilityIDN(ifapplicable) ft. ft. . I1 2i, IU1.4
l4--5U ��[SG(-Y' t , ft. ft.
Physics Address,City,and Zip • ft. ft.
C '}D ti / 21.REMARKS
County Parcel Identification No.(PIN)
—
•
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: — • •
(if well field,one 1st/long is
sufficient) 22.Certification:
�,� 1735—Ib Dirg ir -5 q��� 1g W C.btoi-it � '1•J )�
6.Is(are)the wel!(s)a)Permanent or Temporary
Signature ofCert ed Well Contracto Date
By signing this-form,/herehv cerlt&that the well(s)was(were)constructed In accordant
7.Is this a repair to an existing well: QYes or 11§No with 134 NCAC 02C.0100 in.!SA NCAC 02C.0200 well Cons(merlon Standards and that
If this/s a repair,fill out known well construction information and explain the nature oldie copy of this record has been provided to the well owner,
repair undo).1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may usa the back of this page to provide additional well site details or we
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 Is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: /r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D. (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of wel
1•or multiple wells list all depths(Idlerent(example-3@2 0'and 2@/00') construction to the following:
10.Static water level below top of casing: 6 6 (ft.) Division of Water Resources,Information Processing Unit,
((water level Is above casing,use"•1" 1617 Mall Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameter: LP /L (in.) 24b.,For Infection Weill: In addition to sending the form to the address in 24.
above,also submit one copy of this form within 30 days of completion of wet
12.Well construction method: yo��ri construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
_ r
,� Method of test: Ai r 24c.For Water Suntlyje 1niection We11s: In addition to sending the form t,
13a,Yield(gpm) the address(es) above, also submit one copy of tills form within 30 days o
13b.Disinfection typo: ('-fl-IO V/ i1 e_ Amount: ,,GU_ _ .completion of well construction to the county health department of the count;
where constructed.
Form OW-1
North Caroline Depnitment of Environmental Quality-Division of Water Resources Revised 2.22-201