GW1--05516_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor I/In,ffor(matioJJn/:; /j
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ta FROM TO DESCRIPTION
Well Contractor Naer// ft. ft, I '
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NC ell Contractor Certification Number-}/ ,(1 Ze
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Company ame l
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2,Well Construction Permit#: D 5 PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,eta) ft. ft. In.
3.Well Use(check well use); ft. ft. In. •
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- Agricultural ®Municipal/Public ft. ft. • In.
Geothermal(Heating/Cooling Supply) `?ii Residential Water Supply(single) ft. ft. In.
• is Residential Water Supply(shared) :�� 't >;r H*.v,-;
Industrial/Commercial � PP Y di1.8 �ROt7',�?`;_;'���au;'s�>:,��/.?:�''�'.; t:� j�_� "_ <�`- t��:,r:-.s w�;
I Irrigation FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well: • 0 ft. D>� ft. /,,e �r1 �b � - D� Qa tC.Y�
Monitoring DRecovery ft. . ft. • J
Injection Well; ft. ft.
Aquifer Recharge 0Groundwater Remediation AXIOM ... �EWPA 3CC(t�lipll6giblp) r n; O ' z :tti
Aquifer Storage and Recovery ' OSalinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. , ft.
Experimental Technology ,,,,,'.Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer `ZQ+ 13II)i)N :0; l(tt }��'!ti i'sl uii 8)i�;eW?1f iie �'= `='z `l€g f.
i'D L G G: a ail p d ti € 'ire�S�bYS� "�. '�="'
FROM TO DESCRIPTION(color,hardness,ion/rock type,Rule size,eta)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) f
0 ft' JSgft, di.✓tC.-1AI
4.Date Well(s)Completed: -1'rb .L.1" Well ID# t 4 Oft. ..q�51t. — 1� , ,� •A .,,�-- 4
ft. .fn- ft. (� �"y a_".� .. '
Sa.Wei Location: ik'�-�'4'+" s/y7'I
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Wl G� ��� rt. ft. CEP d 2C24
Facility/Owner Njme Facility ID#(if applicable)
CI V I ! i 10 n fb-A C!/ id a ft. ft. trei.i::.>:.vf n I)f--r 4/'-4;—,c1 f.7'F?
Physical Address,CIil,and
�Zip
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County Parcel Identification No.(PIN) „• • " • '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •••
(if well field,one laattIllong is sufficient) �J { ,h G 22.Certification: /� �/� ,J
< l Al N 0 0�, V 13 W �fj..,TI }� • R"6^'o `f
Signature of edified Well Contra r, Date
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certify that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: OYes or EiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that e
If this is a repair,fill out known well construction information and explain the nature elite. copy of this record has been provided to the well owner.
repair under 1121 remarks section or On the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I 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: r�4" ' (ft.) 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths f(dierent(example-3®200'and 2®100) construction to the following:
10.Static water level below top of casing: • I
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"1/ 1617 Mail Service1 Center,Raleigh,NC 27699-1617
11.Borehole diameter: ` '+ (in.) 24b.For Inlectlon Wells: In addition to sending the form to the address in 24a '
above,also submit one copy of'this form within 30 days of completion of well
12.Well construction method: 0`�a-Ifr y 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: I 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) A 4 Method of test: &I r 24c.For Water Sunnis,&Inlectlon Wells: In addition to sending the form to
.the address(es) above, also submit one copy of this form within 30 days of
t
13b.Disinfection type: l D {^1 Yi .. Amount: IY,t.iiir 5 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