GW1--05427_Well Construction - GW1_20240909

WELL CONSTRUCTION.RECORD (GW-I) For Internal Use Only:
1, ell Contractor Iationt
1C4 yl Infor
It�J f* = - ja 1�5 Atky,fr,9ti i* ;r;,,�tisa:. ,'/;,N,,
1oi G�e, FROM TO DEQ�JUPTIQN
Well Conte otorNamo o ft. ft,
L36A ft,
NC Well Contractor Coitifloallon Number 0 a�11E;t D, Iti'`t` DI M• EfGtt 1ttf1U NMl�jlw)essAY'fi I C1LE IAL
I I FROM TO
(?C1ft J'v 11 owl d 1U 141 0 rt. •
y It. ,„ 2 In' �,0T 2 I �i
Company mo (� p kniailiii� iffira.il.IgiNi).(61.t tWITI` )ltnif}�Tl(Ai3`1,
5 I^/r1 //... -0`v./ (l FROM TO ' .rt" E• HI 4E:S MATERI L
Z.Well Construction Permit NI YVV K. /"`.+ ft, ft In,
List all applicable well construction permits(Le, UIC,County,State,Variance,eft) ft. — In,
fft,
3,Well Use(check well uae)t J:./il�.dta •• `)lltl �t ) r ;t�`'t;p,? r�u�!,it ;,;€,:.,:,:aa:,�i„I...•tt:.;:,i:,
Water Supply Weill • FROM TO DIAMETER 81.0TSIZE THICKNESS MATER)AL
DAgrioulturel
Die MuniolpavPubllo It, ft, In,
ft. ft, In,
Geothermal(Heating/Cooling Supply) Rosldantial Water Supply(single)
Residontlal Water Supply(shared) Lion tvC �ti�,>)A �'Yt:;);�i'.•,;,:�+ w'; , ,,e�;: ":,r,.
Industrial/Commercial FROM TO A7ERTAL EMPLACEMENT METHOD&AMOUNT
Irrigation ft. 2 Q fL ?p�p;+C �f
Non-Water Supply Well: ft It.
Monitorin� QRwovory _
Injection Well: ft, It,
Aquifer Testecharge Dj Groundwater Remedlati°n rtid'9'l A i /ij i L+"4l'Aj (U�I`31CxJf EMPLACEMENT METHOD
Aquifer Storage and Reoov6ry ." Salinity Barrier 0M �o ft, �f E�A4
LyStormwater Drainage R, '
Aqulfer ,�. ft, ft,
. Subaldenoe Control
Experimental(Technology ,t p
11
Traoor 1 �'%� f o.�o; t�'tt�fli'i p'a e' oll.t ordno ):rock;type,Geothermal(Closed Loop) O UElICRIPa : (color,hardnar,wlU�ock type,grate sine,etc.)
Geothermal(Heating/Cooling Return) �Othor(explain under#21 Remarks) 0M ft, (.,,0 ft. I cv
2y Well ID# yi rL yy5 ft,4,Date Well(s)Corh(tletedtft.
It,
5a Well Location; • It. It. �-�I. ``
(-(a r wnen sty se/r It, ft.
Facility/Owner Name Facility IN(If applicable) - 1A
17 fGf... fL _ Y
U1 ljrt (lr f s �aYY►rt F�f7 • • It, ft, AN -
Ph cal Addrore,City,Old ZipWiNINKA -.r •„Y.,`vl i ci?,.• G,,,� rS
Cl [r LL)v,✓tI
County
ParcelldentlticationNo.(PIN) _'.r
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi; —
22 Certification:
(If field,one IeVlong Is sufflolont) _ e3/ 1/
35.nIS8' N - iI.'X 3B' 9 w `/' �/
` �/ Date
Signature of stied Wolf t7bnlrau;or
6,Is(are)the well(s) Permanent Jr temporary was
signing
JA NCAC 02C.0100 or 1 JA that the
02C,01GOJWeIJ (were)
Standards Gd r ds and n accordance
7.Isi this o a repair to an existingu:weltwent ,(Yee io l No copy of this record has been provided to the well owner,
Olds Is a repair,Jill out known wolf copslructfon l+(/brmatlar and explain the nature of the Site diagram or additlonnl well details:
repair under till reinarkcJecllon or on the back of this fart, 23
- ' You may use the bank of toss page to provide additional well site details or well
8,For GeoprobelDPTnlyI Oor is ne de cop Glegthermal Wells IhavingBthe f wells same construction details, You may also attach additional pages If necessary.
construction,only I OW-1 is needed. nidioate TOTALNUMrnrvilTTA .IL NSTRUC'�j.
9. ed: �(�
9,Total well depth below land ie r nt(er
(ft,) 24a. };rgr All Walle; Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(Q'ernrl(example.3Q100'and 1®100) conalruotion to the following;
(It,) Division of Water Resources,Information Processing Unit,
((water ee water level below top of casingr /D 1617 Mall Service Center,Raleigh,NC 27699-1617
level Is above casing,use"+" tO
(In) 24b.For Iniectlon WellstIn addition to sending
hin the
0 day form
of the address
cif n 24a
il,Borehole diameter' • above,also submit one ocpy
of this font;
12.Well construction method; 11 r coneltuotion to the following:
r
(I.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY;
f ForFor Wa'p v 'e 'Inl°cf��---- 1°—�--w l In addition to sending the form to
]3a,Yield(gpm) 3 Method of teat; 24c.the address(es) above, also submit one copy of this form within 30 days of
l completion of well construction to the county health department of the county
13b Disinfection typal Lorr Amount; t✓ whore constructed,
Revised 2.22.2016
North Carolina Department of Environmental Quality-Divlslon of Water Rcsouroee
Form OW-I .