GW1-2021-03822_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor I'nffoorm�ya.,tiot
ZONES!,
WellContractorName a ' M TO DESCRD rlai
. W 6- n a
& 1t I
NC Well Contractor Certification Number
`45::0UTERC mL►MiTERI ble'Ilor O e"
FROM TO
TE iciew S MATERIAL
Companyame i
,P � fL It. in. r vc'
/ /� l zRKIMNEWCASING OR: ING:"eotheimeldmal-loo
2.Well Construction Permit*: /•o 0 l j Z! ! FROM TO DmWrEw I TEEICKNESS !� MATERIAL
Litt all applicable well construction permits(ie.UIC.County.State,Varlanet eta) ft ft. in.
3.Well Use(check well use): R• fL
Water Supply Well: ''17.'SCREENnIS r.'R ti;i<iill'•.i a4:4c,": r' ti;: ,u`i4;-, s:;;:iec; 'a:;
FROM I TO DIAMUER I SLOTSIZE THICKNESS I-MATiutIAL
D. Agricultural OMunicipaUPublie 0 ft ft in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R R
Tn aUCommercial }Residential Water Supply(shared)
zl&GROUT.;
lion FROM TO w:MATERiAt.1.: EMPLACEM6NTMETH0D= AMOUNT
Non-Water Supply Well: ft. t—a ft
Monitoring Recovery R it
Injection Well:
Aquifer Recharge E)GroundwaterRemediation
Aquifer Storage and Recovery Op�Salim Barrier FROM /GRAVEIiPACIC a•- lieablE ,n'•: .a i':;:.,�;;i::,,"CEMIN M
�,f ty FROM TO MATERIAL' EMPLACEUtt01'r METHOD
Aquifer Test [3StormwaterDminage & ft
Experimental Technology ]Subsidence Control ft ft
Geothermal(Closed Loop) [3Tlacer c2o:DR1LLu�tGLOG aftaetisddttlbnalibeetsifa- ems;-; ;3<::', s.=`s: :,::
Geothermal(Heating/Cooling Return) rjOther(explain under#21 Remarks) FROM I TO DESCREMON(color. roillrock eta
fLft or'J sAn `� o✓� mid&7
4.Date Wells)Completed: �/ Well ID#
Sa.Well Location: ft I.tQ ft
'fry/Own ame _ Facilitym#(ifapplicable) ft ft
2yo� r� ;r � rA ft ftMA
Physical Address,C' and zip ft fL
-rJ1 .21.vPM"RKS :: .�� i�y•,r,;•:, j;. >: .,.3 `_`a' ::;,;refs ;v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. cation:N W � y !/o 'Z
6.Is(are)the wells) ertnanent or [3Tempora of fled Weil Date
By signing this form I here tt(ry that f wells)was(were)eonsnucted to accordance
7.IS this a repair to an existing well: [DYes or No with MA NCAC 02C.0I00 or!SA NCRC 01C.0200 Well Construction Standards and that a
lfd&is a repair,jilt out known well construction information and explain the nature ofthe copy of ft record has beenprovided to the well owner.
repair under#21 remarks section or on the back ofthisform. i
23.SIte diagram or additional well details:
8.For Geoprobe/DFT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. t SUBMITTAL INSTRUCIIONS
9.Total well depth below land surface: 249. W F All or ells: Submit this form within 30 days of completion of well
For multiple wells Art all depths V-different(example-3(d1200'and2@1005 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resonr Ies,information Processing Unit,
lfwaterlevell:above coring.use"+ 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: /(in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this,'form within 30 days of completion of well
(Le.suge,rotary,cable,dingy pushy etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699/636
13a.Yield(gpm) Method of test: / t 24c.For Water Supply&Injection Wells: fIn addition to sending the form to
the address(es) above, also submit�oue'copy of this form within 30 days of
13b.Disinfection type: Amount: ti+ L.— completion of"well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEavironmental Quality-Division of Water Resources Revised 2-22 2016
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