GW1-2021-07594_Well Construction - GW1_20210903

For Internal Use Only:
WELL CONSTRUCTION RECORD(GMU)
1.Well Contracto,r,yI�nformation:
d:: R ONES.`>�:::� ";j:>;•' e::
FROM O ESCRIP T ION
WelliContractor Name ft. ft.
33Y1- ft. ft.
N Well Contractor Certification Number 9. ...:EIZCA6
ago-wit ;m _ .(;pg
--
G � ROM O IAMETER THICKNESS ATE IAL
mpany Name %' Qfo &0 ft Z —in G
2.Well Construction Permit#: 202,0^00O0 24tt0 ER�!'131.: Pik
G: etdtiiist[riai��t�a�aa;!))
Lief agAwNc fide waft—ft1diAlINMAN(re.UIC,COW%Slate,Vadww,Oft) � :. ..
ROM O IDIAMETER [THICKNESS TERIAL
III ftl in
3. Well Use(check well use): in
ater Supply Well: ,
Agricultural 13 MpaVPubllo O METER LOT SIZE HICK ESS TERIAL
yicij
Geothermal(Hesting/Cooling Supply) ResldeMiat Water Supply(Single) ft in
IndustrlallCommerdal ❑Residential Water Supply(Shared) ft in
Irrigation ,(_._. .".� :e:...::Ki_; _ :•�': 't3_ '.fs_.::.. ,,:. .."_^:.
ROM O ~ATERIAL MPLACMENT METHOD&AMOUNT
Non,Water supply Well: D ft ft ar
❑Monitoring Q Recovery ft
Injection Well: ft ft r
13 Aquft Recharge ❑Groundwater Remedletion ROMro E L MENT METHOD
C3 Aquifer Storage and Recovery 0 Salinity Barrier ft ft
❑Aquifer Test ❑Stonmvaler Drainage ft ft
E3 Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ROM"; O ESCR O (color,hardness,soilhod(type,grain,size,etc.)'
❑Geothermal(Heating/Cooling Return)❑Other(explain under#21 remarks) ft ft
ft 4.Date Well Completed: Well ID# ft
So.Well location:
ft R
73W _ ft
FacIR !Owner Wme n F'acility ID#(if applicable) ft ft/.59 4 f yrey,r l�`?��
ft ft sg�
Physical Address ity and Zip
County Parcel Identification#(PIN) ti
5b.Latitude and Longitude in degreeshninutes/seconds or decimal 22.C R A cn
degrees: s G ld`
N W nature of Certified Well Contractor Date
afgrft fhls norm,I hereby ear*that Ore wWs)was(were)consbuated in accordance wf&15 ANCAC
6. Is(are)the well(s): 13Permanent or ❑Temporary 02C.0100or15ANCACO2C.0200 Wag ConahvotionSteadards and fhefaGmofEdsrecordhwbwn
provided to the weLowner.
7. Is this a repair to an existing well: ❑Yes or O No 23.Site diagram or additional well details:
N this Is a repair,fff oid known weft construcillon Wormtlon and explain the nature of You may use the back of this page to provide additional wall site details or well
the repair udder#21 remarks secbbn oron Me back of thle form abandonment details.You may also attach additional pages M neoessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the SUBMITTAL INSTRUCTIONS
same construction,only 1 GW 1 Is needed. Indicate TOTAL NUMBER of
wells drilled: 24a.For All Wells:Submit this form within 30 days of win Metbn of.H.,tucW,to
C the following:
9.Total well depth below land surface: O © (fL) Division of Water Resources;Iniformation Processing Unit,1617
For mulftple wafts fist aft depths tf dftherent(example-3@20(r and 2®fW) Mail Service Center,Raleigh,NC ZM111-1617
ill.Static water level below top of casing: Lo (ft.) 24b.For injection Wails:In addition to sending the form to the address in 24a above,
!f water levef Is above caa ft use'�'/ also submit one copy of this form within 30 days of completion of well construction to the
11. Borehole diameter. lD (in.) following:
L Division of Water Resources,Underground Injection Control
12.Well construction method: �! A&r gLr7 Program.1636 Mail Service Center,Raleigh,NC 2TSM4636
(I.e.auger,rotary,cable,direct push,eta) i
24m For Water Supply&Iniectlon Wells:In addition to sending the forth to the
FOR WATER SUPPLY WELLS ONLY address(es)above,also submit one copy of this form within 30 days of completion of well
13a.Yield(gpm): Method of Test y'f construction to the county health department of the county where constructed.
13b.Disinfection Type: Amount
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 2-22.2016
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