GW1-2021-04332_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor I pop:
o (9/ /J/i o 14.WATER ZONES
Well Contractor Name FROM
�o y fL TO DFSCREMON
6c�fL
NC Well Comractor Certi�c,6�,*ber 15.OUTER:CASING`'(for -tased'welb OR LiNER der
FROM TO DIAMETER MA RIAL
Company Nam
/C) OdO — P /DWr FROMNE1t�ASIl.TG:OR:TI-DIAM. '' closed
2.Well Construction Permit#: G FROM 7'O DIAMETER TH[CIQVESS MATERIAL
List all applicable well construction permits(I.e.UIC.Cowity,State,Variance,etc.) is
3.Well Use(check well use): & 1D
Water Supply well: :;A1,SCREEN._:
FROM TO DIAMETER! SLOTSIZE THIC[NMIZ MATERIAL
Agricultural [3M paUPublic g in.!
(Heating/Cooling Supply) midential Water Supply(single)
in.
In l Q dustrial/CommerciaResidential Water Supply(shared) ft
;:1tt GRUNT r'
�i 'on FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ` Q ft C'on P�✓t--I � ��. 0 r
Monitoring. DRecovery ft fL
Injection Well: & fa
Aquifer Recharge ®Groundwater Remediation
;.19.:SAND/GRAV£1:`PilCR.. .
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. fL
Experimental Technology Subsidence Control fc fL
Geothermal(Closed Loop) ®Tracer 3 DRELJJM,:LOG..atmch iaig-r>ee�:;f
_ Geothermal eatin Cool• FROM TO D ON(color.hudo,soil/rock sire,eta
(II ) CKlter(explain under#21 Remarks
o y R lr
4.Date Weil(s)Completed: 7 Well ID# fL d s f
s
5a.Well Location: fa fc
1� e-P -
Facility/Owner Name Facility M9(if applicable) ft ft
36�� a/�f ge k Ilc�, ft &
Physi Address,City,rd Zap ft. fL V
2L:REMARt3S
_.. .....
County Parcel Ideftficarion No.(PIN) PCOC+e
rI pVVR
56.Latitude and longitude to degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
W r�
6.Is(are)the well(s), Permanent or Temporary Signature of Certified Well Co. or pare
By signing this form,I hereby ce4 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 0<0 with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If dds is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider 021 remarks section or on the back of this form.
_ 23.Site diagram or additional well details:
S.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 1 GWA is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dnlicd. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths y1ijferent(example-3Q21 'and 2Q1001 construction to the following:
10.Static water level below top of casing: n (ft) Division of Water Resources,Information Processing'Unit,
lf water level is above casing,use"+ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: a n./1
(i.e.auger,rotary,cable,direct push, construction to the following:
aug !
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service�CCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) o Method of test: te-ci,r 24c. For Water SunDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: !�T/�f Amount `/ G t completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 2-22-2016