GW1--05833_Well Construction - GW1_20241001

WELL CQNSTRUCTYOJ{RECORI? (GW-fl or interne se On yl —
1,Well Contractor Inlormatlo Irr��((�-y. yvv r �a/�(r ,fi we
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Well ComreotorNa�n �]
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NC W I Conheotor Certification Number M a�Ii)?T3(f:.J) �]'ICfi?ii 1G(T(3X'Y),l�t'JIIS1 till .f' Tsisinolli
ESSES
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Company Nam J+J /L� 11:ilil�li):7SifNy NI? otl�.tiliM!iSF).(6�41�I1MIltif rif?`IRIVi �
MINNINOMI
O2 ✓, 7 'g itiOu TO to knit ta:�rttilL'L�r�r1_
COMMININIMI
2,Well Construction Permit HI ft, ft. In. —
LW all applicable well consu'ucllon permits(l.e,U(C,County,Stale,Variance,eta) ft, ftIIIIIINIIIIII
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3,Well Use(check well use); //IE � ;}ly,alAMMIC{ii'�?�Eli Y
Water Supply Weill ,;r„ o r .u17tlTrr1111 to s x• =�
Agricultural �
Muniolpal/Publlo ft, tt, In,
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Ceothormal(Heating/Cooling Supply) 0Residential Water Supply(single) ft, ft, .�
IndustrleVCommercial DResidontlal Water Supply(shared) ���y�oleh�men. •I,:i:4�R
MEMMIll
FROM TO ATERIAL E P ACEMENT hi'THOU&AMOUNT
irrigation It. 1'i2_ C%11 e. .� bd.f )v({Yd-,
Non-Water Supply Well;
Monitoring
QReoovery tt, ft.
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Injection Weill ft' It.
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Aquifer Recharge DOroundwaterRemedlatlon• ►iR .v Irli {i a�i(_E alINIMMIESIMEMIMINIM"11
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Aquifer Storage and Recovery OSalinity Barrier ilr0 H ,II' IS RI Aquifer Test ;.�'s; [ StormwaterDrainage —
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Experimental Technology \'.,5 OSubsldenoa Control
, r a� t e a s TfJltl�tf��YiO�'J713`�7�"I�P�1A'�'
Geothermal(Closed Loop) ( Tracer 1 �1A 1t .�1�'�11 t3C1ti9G"C�1 `C
PRO TO DESCRIPTION color hardnrn wl rook •r 'rain size etc.
Geothermal(Hoating/Coollnj Raturn� 110thor(explain under f#21 Remarks) D ft. MI , /(f (Q Z /'Ci i)c_I
q ,, 4-.D-1 Well . �Jtb (� D�f6 r�1l e
4,Dale Well(s)Corhpietedl / rt.
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Sa,Well Location; ft, ft, `'
�t Q 6c yv1- U .JP_ yLYtl ,(..: I JYL rt, Its
Facility/Owner Name Faollity ID/4(If appileabie) —
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Phyaloal Add ;,City,and Zip {'edit i ;r.a;ti,:: k`,0 .:,yC •.'•.. I"
12510
County Parcel Idontl0ostlon No.(PIN) _-.r
5b,Latitude and longitude In degrees/minutes/seconds or decimal degreesi: 2Z CertJiicafiont
(if well field,ono�IeUlong la�ayu(ilalont) ` ,„��.y./
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b.Is(are)the we4 Sign ro of certified Woll Contra are(s) Permanent ar Temporary By signing this form,I hereby tuna that the well(s)was(were)constructed In accordance
out knob+well
or �No ' with atNCAC 02C.0100 or ISA NCAC 02C,0200 Well Construction Standards and Ihat a
Ulhfs Iss a repair,Jill
7.Is i a repair an existingwell; DYescopy is record has been provided to the well owner.
abopslruotfon 1+1/brmaua+and explain the nature ojrhe o th
Site diagram or additional well details;
repair under k11 rehtarkfrgplion or on the book of Ibis form. 23.
You may use the back of this page to provide additional well site details or woll
NUMBER•
of wells construction details, You nay also attach additional pages if necessary,
c For Gion,o only 1 O or isC ed needed. Uidlo to TOT Wells havingthe same
construollon, 1 OW-1 is itidloafeTOTALoiInM1TTAL INSTR 1 ILQ�
drilled;
9,Total well depth below land surface; C-P- 0 5 =(f.) 24a. For All Walla; Submit this form within 30 days of oomplotion of well
For multiple walls list all depths(fd(fjerenl(example.3@200'and 2®100) construction to the following;
(') _(It,) Division of Water Resources,Information Processing Unit,
1
If ter levcel
water level below ow top of casing; �—_ 1617 Mail Service Center,Raleigh,NC 27699.1617
((water In above casing,use"+"
I cj (in.) 24b.For Inieotton Weller In addition to a hinin the
0 day form
of oche add ress cif n 24a
11,Borehole dlamotort above,also submit one copy of this form
ell
oonetruotlon to the following;
l.o Well construction cable,
mcthodt
(I,e,auger,rotary,cable,direct push,ale.) Division of Water Resources,Underground Injection Control PrOgram,
• 1636 Mall Service Center,Raleigh,NC 27699.1636
FOR WATER SUPPLY WELLS ONLY; t *,,��,,���njj3t in addition to sending the form to
Q i t~ 24c,For Water SunD1��f.111tudi i1 of thistform within 30 daysrtof
o
13a,Yield(gpm) Method of test; rho addreee(of above, also submit ono copy
( tit
�5 oomplotion of well oonstnlaUon to the county health department of the county
13b Disinfection type' Y Amount; whore eonatruoted.
Revised 2.22.2016
North Carolina Departmotrt of Environmental Quality•Division of Water Resource;
Form OWI