GW1--05428_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information; t
T. g aN
D'
1i�luPTt
Well C6ntraotor Neme ft, ft,
I U` , 6 ft, ft.
NC Well Contreolor CeriIl1oIIofl Number S4CjO �!1RAFE' `)fit`)"4 d t it: L IAL
.,`.
,.�1 J J PROM Tr DI E E THI K__ MATE
►'•4rn s �il( all CI Pv{�lIj� ft, I 0 it,
�` in,
S L V
Company roe TO Dl(zMP.T&R _THICKNESS MATERIAL
2.Well Construction Permit#; S 1a/2 3 -0 23 2 FROM ft, tL In,
Lie all applicable well construction pond!:(Le, WC,County,State,Variance,etc) ft In,
It,
3,Well Use(check well use); - 11k �1a1�? )iti$ i ft ? R,9:.avw�,)l=:^ is+.;f;;:'•,l':fit,::4.;..: :'
tr:r• ,
Water Supply Welk FROM TO DIAM1 - ' 1 L. 8 Z ICKNEss MA ERIAL
•
Agrloullural
Munlolpal/Publ a n, ft, In,
In,
Geothermal(Heating/Cooling Supply) ORosldantial Water Supply(single) tL ft, � .
IndustriaVCommerclai [,;, Residontlai Water Supply(shared) ) ;(byte_ ;Dk�,;;)st3i°fit:,i3;�(?j',° ?
�'tr7RO�M TO 6 ATERIAL EMPLACEME METHOD&AMOUNT
Irrigation V It' 2'0 ft' _Je I: ��A e ••
BERNMIl
Non-Water Supply Well; ft. ft.
/
Monitoring �Rcoovory _
ijection Well: R, fa
Aquifer Recharge ©aroundwaterRemedlatlon ,�y�ryiIlj��r '' ".`s '�'"�''1`' "`"
o MAT:RtA 'MI I ACEMENT METHOD
Aquifer Storage and Reoovhry Oi Salinity Barrier •
'O ft,, ft,
Aquifer Test `. 1 Stormwater Drainage —
Experimental Technology .,;,t OSubsidenoe Control �p�� a��y��ry�{r }�
VERT `g�!L{lL`J:BWInt11,g ,0'. '0: 4i1 .D:,Ad ir.);.:9,.ti�Yit,•;••'' ',..,,.
Geothermal(Closed Loop) �Traoer PROM TO DESCRIPTION color hardnnr ,olVrock .r .rain size tic,
Geothermal(Heating/Cooling Return) nOthor(explain under#21 Remarks) O ft, Ib it. C J a
4,Date Well(s)Corhileted;0 0LZ2/2Li Well ID# • 11111111k1=1 .2
5a,Well Location; ft, rt.
�rnn1V I4n0(kS ��r u 9 2Q2d
o� rt. ft.
Facility/Owner ems Facility lOP(Ifeppllesbie)
ft, ft,t rt �X r' ft. ft.Phy loaf Addis's,
we,CII ,and Zip ft.
hYul3lJi a;,>-.. 1: 'v'?: r�;L;'.Y,;
County
it l ��d Parcel Identification No,(PIN) _-.s
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi 2Z CCertification:(If wall field,one let/long Is;ancient) • , ✓/ �,)0<
3 5 l 3 z27 N - X 1 • Ct a (3 w 6� V A
` Date
p-�, S gnaturo Gertltlad Woll corrector
6,Is(are)the Well(a)>�Perlrmarient sir C.�rTemporary By signing this form,I hereby GerlIf'that the wall(s)was(were)constructed in accordance
with/1A NCAC 02C.0100 or I54 NCAC O2C,0200 Well Construction Standards and that a
7.Is this a repair to an existingiweiiwell; :Yes !s �No copy of this record has been provided to the well owner.
((this Is a repair,Jill our Knott'r wain catistruc;lvi:1: -r::-:•-:'^^d explain the native Wale 23.Site diagram or additional well details:repahp under ill1 reinarkr-merlon or on the back of this form.
You may use the book of Ihia page to provide additional well site details or wolf
8,For Geoprobe/DPT or Closede d Ij d ieothermal Wells having the same
construction,only I 0W-1 to needed, Itidioate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary
TA►.INSTRUCTjQ1Y•$
drilled:
9,Total well depth below land surfacer______LC2-5---
(ft.) 24a, got All Wells; Submit this form within 30 days of completion of well
Par:mdiple wells list all depths(fd(Q'eretu(example-3®100'and 21g1100') construction to the following;
�p Q (ft.) ' Division of Water Resources,Information Processing Unit,
10.Staticr lewater level below top' casing; 1617 Mall Service Center,Raleigh,NC 27699.1617
((worstleveliediambove tern ,use"
(in.) 24b.For submit
elcop In addition to wIthtln 30 days of come address pletion on eln 24a
f well
t 1,Borehole diameter' above, also submit one copy of this form
oonatruotion to the following;
12.Well construction method: t7
(I,e,auger,rosary,cable,direct push,oto.) Division of Water Resources,Underground Injection Control Program,
• 1636 Mall Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY;JL Injectionin—W
Well,t in addition to smtding the form to
Method of test; v 24c,For Water SLDDLY§E�
13a.Yield(gym) the addresa(os) above, also submit one copy of this form within 30 days of
t; (� completion of wall oonstruolion to the county health department of the county
13g,Disinfection typa�_ Amoun where constructed,
Revised 2.22.2016
North Carolina Depadmmu of Environmental Quality•Division of Water Resource'
Form OW-I