GW1-2021-00667_Well Construction - GW1_20211222

CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
pod IA.WATER ZONES
i
Well Contractor Name FROM TO DESCRIPTION
ft^ . ft
Q
�U( A
!
NC Well Contractor Certificatio rim
ber /t 15.OUTER CASING for mnl6-cased-wells OR LINER`if-a "Heable
�.a FROM TOTER THICKNESS MATERIAL
( 3 ft. in. c'
Company Na 16 INNER CASING OR TUBING e
^) ofhermai closed-lo
2.Well Construction Permit#: �' pl FROM To DIAMETER THICIeff S RATERIAL
.c List all applicable well construction permits(i.e.U1C,Couary,State, Varidiie,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11 SCREEN
FROM I TO I DIAMETER i SLOT SIZE I THICKNESS I MATERIAL
-)Agricultural g
icipal/Public ft, ft.
Gcothctmal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared)
i$.:GROU'C
Irrl ation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. d,p ft G a ryty�y
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
19:SAND/GRAVEL PACK'If aliceble
FROM TO MATERIAL EMPLACEMF-NTZ-1-1
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer 20.DRIL ZING tiOG atiac6-additiontii sheets it necessa
FROM TO DESCRIPTION color,hardness,soiVrock
Geothermal(Heating/CoolingReturn Other explain under#21 Remarks)
fL ft fjjAsOf
4.Date Well(s)Completed: (t` '5-0,! Weu ID# Lie 0 it. f Q f [rz)aGk
rVh�y{ ,/ ft. ft
U ��.1 piZ ft. ft. nn .rr., q n
Facility/Ojw�ner Name Facifiirty�ID#(if applicable) O E C 2 2021
21
t/ e` ►J dikl, C/ ft. ft.
A no•nri.^.A
Physical Address.City.and Zin ft. ft.
2L REMARKS
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer cation•
N WAggll
6.Is(are)the wells) . Permanent or 13Temporary Signature of Certified el on ctor Date
By signing this form,I hereby certify that the well(s))vas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
- Phiv iu n-Tn i'r fit n•., —4-7hyli-ihn!.ghrro.,rear copy of this record has been provided to the well owner.- -- - - - - - -
repair under#21 remarks section or on Me'back of this form.
23.Site diagram or additional well details:
8.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
___ _ _ __ _ e..!�i!!!rinn-i m4H;h y,!!!!m:ev
dyed: SUBMITTAL INSTRUCTIONS
J !Etta!earn S!rf 1h hnt..ee•',n w., ••lo nn• 1 0 O ¢� !!f l e — -
;... cvnstrucUun Lu Lim iuliu)v k
10.Static water level below top of casing: J V D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casuig,use"+„ #1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ct If rt-, r/ construction to the following: `
(i.e.auger,rotary,cable,direct push,etc.) P
i
Division of Water Resources,Underground Injection Control Program,
13s.Yield(gpm) Method of test: 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
t� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ►1 Amount: v ' completion of well construction to the county health department of the county
where constructed.
f
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016