HomeMy WebLinkAboutWELL-01-2022-163988.TIF =,_ -,
LL CONSTRUCTION RECORD(GW-1) -For Internal Use Only:
1'Wen Contryctor Information:
11,WATER ZONES —
Well ComractorNeme FROM TO DiaCRR17ON
ft. n.
— _..__2(2 n. IL
NC Well Contactor Certification Number
15.QtttER CASINO(for matt{-toed Veils)OR LINER off appio
r� r�'f J et*, To _ DIAMETER THICKNLa6 Ij 6,,...T.,
[�ALYWAi
C--s'(n yhi ii,e J 'f 0 fi. 6 ft. In.
°mP�y Na
' 16.INNER CASING OR Ti==thss erai dose 4.op)
2.Well Construction Permit tM: )3 PROM TO TinCKNtaa _MATERIAL
Llrt all ap,Iko.b a moll construction pentdtr(r e. UK'(crimp.,State t'nrfoncr,eft.) A. ft. in.
3,Well Use(chedt well use): n. O. In.
water Stsppty Well: 17.SCRREN
M
FROM _ TO DMXTtR atm a11Z , THICKNESS MATERIAL.
Agricultural QMunkipal/ruhlic fe ft.• In.
Geothermal(Hating/Cooling Supply) residential Water Supply(single) ft- n la.
Q I ['Residential Water Supply(shared) It mom. - -
nlrrigation FROM ,,TO MATERIAL. _ EMPLACEMENT METHOD&AL4ocirr�,
Noa-Water Supply Welt: tJ It. 20 tt. ,let ? , _
laMotitoring DReoovety ft. ft.
Infeeden Well: '
• ft. ft.
Aquifer Recharge n(�rroundwater Remediniicm
Aquifer Storage and Recovery ['Salinity Barrier sito19.SAND/GRAVEL
itt� RATO PACK MATERIAL� EMPLACEMENT METHOD
Aquifer Test ['Stotmwater Drainage R. ft.
rliaperimental Technology ['Subsidence Control It rt.
°Geothermal(Closed Loop) ['Tracer *DRILLING LOG(mach addlnottal Metes If eeeesaary)
FROM TO DESCRIPTION War,hardness,*Windt t a5gr.doer ON.)
f Geothermal(Hating/Cooling Real) [ e. r�
0 3(j ,I t/l/+
Other(explain under#21 Remarks)
,/
4.Dote Well(s)Completed:`1/_(0/12_) Well 1oif , 3 0 R' CO ft' , /5 00//1 bi
31.Well Loca /
tion: LP 0 ft iJ [} fl lat. koC 1"
La
' gaalty/pnmr Name Facility ID (if applicable) 1 'R
51 O(' 1--6 cite. 1-n, S1�rril1s Ford J)L a$C73ft.
ft. ft.
ft.
Physical Address,Cay,ants zip
• C + 0,1.4 1 21.REMARKS
Ca
may �j& Panel Identification No.(PIN)
•
' 3b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(Knell fxid.one lat/long is sufficient) 22.Certification:
N W
flai‘
6.le(are)thevrelt(s)�nent or ['Temporary
Signore ofC eel Well C or Dike
� By signing this form,I hereby ratify that the wens)*us(were)coetbam cn tt in amnian
7.1s ibis a repair to an existing well: ['Yes or f }t with!SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Coaunatioa Statdanir and thee a
(/this 1s a repute,fill out known well conefntctkon information and explain the nature of the ropy of MO record hat bees provided to rite well owner.
moat,rodeo wit remarks section or on the back oflhlsf rm. 33.Site diagram or additional well details:
L For Geoprobe/DPT or Closed-Loop Geothermal Welt having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
• tidlled:_ _ SUBMITTAL INSTRUCTIONS
9.Total wee depth below land surface: id c (ft.) 24a. For All We{l: Submit this form within 30 days of completion of well
Fee..Erie coed{Art all depart(VOtfJerent(example-$l200'and 1010iY) construction to the following:
10.Stade water level below top of casing:!I'w (ft.) Division of Water Resources,Information Proceuing Unit,
rer level le canny ass"++^ 1617 Malt Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: fa I'y, On.) 34b,Fig lilt:Won Wells: In addition to sending the ham to the address in 24a
It Weil ansttttefyon �: above, also submit ono copy of this form within 30 days of completion of well
meth(ie_auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: of Water Resources.Underground Infection Control Program,
1634 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(grin) 20 Method of test: A Ir` 24e.,For Water Simply& Inlecdon Wells: In addition to sending the form to
(� the address(es) above, also submit one copy of this form within 30 days of
13b.Didnfeetiva type: Ill 14>-Elt� Amnon{{ a _01 completion of well construction to the county health department of the county
where constructed.
Form OW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016