HomeMy WebLinkAboutGW1--05515_Well Construction - GW1_20240912 i -
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WEI,L CONSTRUCTION RECORD(OW-11 or nterna Use On y:
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1,Wel/ll]Contractor Informatl° 1 •
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Well Contractor Name ft. ft,
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• NO WellContraotorCertificationNumbor t ,
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2,Well Construction
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2,Well Construction Permit#t
Girt all applicably well oa+sn uatlon Permits(l i.WC,Co (100,JtState, r4 r1,Variance,do) MIIIIINIIII
MillailMilillaNINIM
3,Well • ft, "' NMI
u110113.11 1�1� �1=011�`� 'INTAIM V �
Water Supply(checkwell use)(ply Wentv;." R`��IrragrgaTill '
�1 Agricultural
Muntoipal/Pablio ft, ft, 1,. In, ��
Roeldential Water Supply(single) fG fb
• �Geothermal(Heating/Cooling Supply) � 4 �� r i �����+��� ;�� :���•',� .•'
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*Industrial/Commercial ORo,lidentiai Water Supply(shared) ifillc�{o1�.Ti3'i/�'m ,lP R1 13tCFP�{ �1 E P.:Ca 'NT 'T On& MOUNT
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l on.W atn C' f6 (ieit-1-n 1 e b a y- _/o l.Ur e a
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Non•Water Supply Well; tt, . ft'
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*Aquifer Warp; ®GroundwaterRemedlatlon t M f,R1;ISHIA Q,}ty{ ;{yj1tlrt{i.i Y�I liatil arnoo
Salina Barrier °� r"b' i�
1�Aquifer Storage and Reuovbry tY
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�`: Stormwator Drainage -
R;Aquifer a• •, It, - ft,
Ill Experimental Teobnology :,•' ;,;�`` • DSubeldenoo Control R T ! .
Tracer 'ifi3'i�iiti1tiL`.AIII,XsZCi`.(iCt'1 DU'I90RI TIlI coo�Phordnm co rock yra.rotndxe'Na5 .,
MP Geothermal(Closed Loop) FRO l� To r
X Geothermal(Hooting/Cooling Return) J"`.t Oihor(explain under#21 Remarks) b ft. 1,n 1
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4,Date Well(s)Cod101etedt11- tt, ft,
5a ell Locations ft. ft., ��:_ ' Q , �'
p iv)r �'�l'r'S ac- �u1�Y�5 •
Ron Name ' Facility IDN(If applicable) a, ft, • '4 l 74
I J- (�A 1 ) (t, ft;
Physical Address,City,and Zip
G.. tint°I •
County Parcel ldenhlficsllOflNd.(PIN) •,s
5b,Latitude and longitude In degreeelminutesleeconde or decimal degrees(•t • 22,CvrNtiaaHont
Orwell field,one leVlong issuftlolent) i I •
r o��'
y' •
,; 8lgdsturoeeAitied Woll!~bntraolor
6,Is(are)the wells) Permanent �r -''Temporary y signing thlt finer,/hereby oarlW'that the well(s)was(were)constructed In accordance
o • with IM•NC4C 02C.0/00 of 1JA NCAC OJC,0100 Well Conslractlon Standards and ilia!a
7.Ia this a repair to an existing well; QYes or � .• oj copy gffl+l�record has bean provided to the wdlawncr+- •
((Ws Is arepair,pNoaf knob►well consfruorlon ht/brmatlon and explain the nature tlre 23.Site diagram or additional well detatlat •
repair under P11 riltuir�•.sgjtlon or on the back gflltlsJbtv++,
8
0o You truoy.use
the
el book
k of this pagelso to provideh aid i not ion pages If eneoell osdetails or-well
c For Leon,onl OW.1 or is Clo edv needed,
•to (e TOTAL
NUM having the same
( TION
constnrvtlon,only I is ltidloafe TOTALNUMBHR of wells e;,nnanlT•rAL INSTRU
drilled;
24a,ggr Ml Walfst Submit this tbrm within 30 days of completion of well
9,Total well depthi below s(fd(Obrefaeet 00'and 2®00') construction to the following;
For rmdttpfe wells flat all depths(fd(pbreul(example•J® �
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" " . 0Q _(ft.) . " DIv19IonofWaterResources,Information recessing nit,
(0.Static water level below top.of casings 1617 Mali,Service Center,Raleigh, ,
((wafer Wel I:oboe:ice:ring,um
(in,) 24b., Ina ellati In addition to wIthnng3h say ofcompletion of well
11,Borehole diameters above,also submit one loopy of this foprr
rm to the address.In 24o
0 �t_ construction to the following, • • •'
12.Well construction methods Underground Injection Control Program,
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Reaburees,
163E Mail Service Center,Raleigh,NC 27699.163E
FOR WATER SUPPLY WELLS ONLY; , 24c.g -ter innly 8 Inleatlon WeuSt in addition to sending the form lc
r rho addraes(ee) above, also submit ono copy of this form within 30 days oc
13a,•
Yield(gpm) t Method of tests %�. completion of wall oontr`uotlon to the county health department of the count)
Amounts whores conatruoted. I
13b,Disinfection types Revised x•2z•zot
North Carolina Department of Environmental Quality•Division of Wrter�Resources
Form Cw•i I'