GW1--05426_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:: •
�a rr�l I 19000C(.e r
lla FROM TO DESCRIP
TION
WellContreclerNews n, ft.
61 5 `I 5 ,4 ft. ft.
NC Well Contractor Certification Number ..IS.,OtlORCASINg,(ter u►ti.easawe)If)"Ol2bINL'il`(it;ap limbic) - •.•. '
enH / f FROM TO DIAMETER THICKNESS MATF,RIAI,
1 6 W��CXt4LJ POW, DIAMETER` fr. 5 Q rt. 1 ./2 5 In. 5p/ i r to
Compan(Name 16'I • ,.: •NNE2t CASBVG oft J I1$1'Y('(geoth@)'mlepetltluop).
2.Well Construction Permit N: _SWZ 3/2`I-06 23 FROM TO DI AMETEK THICKNESS MATERIAL
List all applicable well conshvcllon pumas(i.e. U/C,County,Stale, Variance,ale,) ft. ft. In,
ft, ft. in.
3.Well Use(check well use):
, _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipaUPublic ft, ft. In.
Geothermal(Heating/Cooling Supply) ggResidential Water Supply(single) ft. ft. In.
Industrial/Commercial DResidontial Watcr Supply(shared) ` 18,.QROUT • . •
Irrigation FROM TO Z ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 2 G fl. I/GK�tG�G (/�q�^S y�OKtrCD
Monitoring DRccovcry ft. ft. G /'
Injectio❑Well: —
ft. ft.
Aquifer Recharge DGroundwater Remediation 19:gpND1CRAVEL%PACK'(If app)Iceblo)
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. rt. _
Experimental Technology OSubsidence Control • ft. ft.
Geothermal(Closed Loop) OTracer • 20,DR1J,L;G LOG.(attSelt ad;litlonal-sheete,iLpecessM'Y): „
FROM TO DESCRIPTION(color,berdaeu,rolVrock type,grate etu,etc,)
Geothermal(Heating/Cooling Return) rliOther(explain under#21 Remarks) 3 ft. SC ft, C'ay
4.Date Well(s)Completed:N/2�y,�2-I Well ID!, 5 I ft. 309 ft. .1!
r I 'G�
5a.Well Location: ft. ft.
ft. ft. , f.,
.rirl.try�. SVa re,2 �•t:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
CIP.ar wafer rC(f'k► ety ft. ft. SEP e 8 2024
Phya'cal Address,City,and Zip / ft. it.T
ad11.-afford Ir I— .7.:
21.,I{i NtARY(S :.-- .rr�a..;_
I
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one ladlong Is sufticienl) 22.Certification:
35.NI1g5 N Si.gcl37y W 51""?21/
Signature of Certified Well Contractor Date
6.Is(are)the well(s)laPermanent or OTemporary
By signing this'form,I hereby ouv(fy that the well(s)was(were)constructed In accordance
7.Is this u repair to an existing well: Dyes or 111}No will,154 NCAC 02C.0100 or 1JA NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,J1ll out known well consnvm/lon information and arplaln the nature of the copy alibis record has been prouded to the well owner,
repair undo,.1121 remarks section or'on the back of this Joan. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
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: SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: 30 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf dif event(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 140 (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
y� f_. above, also submit ono copy of this form within 30 days of completion of well
12.Well construction method: !' O TGt✓}I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air 24c.For Water Sup lv 8c lniectlon Wells: In addition to sending the form to
�+ I- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typo: l I llloti1Yl- Amount: LI ,C19S completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22-2016