GW1-2021-00699_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Isx
14.WATER ZONES I
Well Contractor Name
FROM TO DESCRIPTION
lY� ft. ft. W SAn
ft. ft. Vl
NC Well Contractor Certification Number
T 15.OUTER CASING for multi-case&Ivells OR LINER if a lieable
( )Y1�l I FROM TO DIAMETER THICKNESS MATERIAL
y ` J/ t- ft. 13g ft. a in. 5�r �a P\1L
Company Name
0��J � � � 16.INNER CASING OR TUBING m cothcral closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e, UIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:.,)Agricultural E)Municipal/Public 1548rft. tuft. a in. AO\C
t Geothermal(Heating/Cooling Supply) R:)Industrial/commercial
Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Sit. /1 10 ft. _ �-
Monitoring Recovery ft. v� ft.
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
'
Aquifer Storage and Recovery r.lISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test I Stonnwater Drainage a© ft. ft. # a --,CLr\CA 0QQ
:)Experimental Experimental Technology Subsidence Control
Geothermal(Closed Loop) rnITracer 20.DRILLING LOG(attach additlonal sheets if necessa )`
_ Geothermal(Heating/Cooling Return) (explain under#21 Remarks) FROM To DESCRIPTTON(color,hardness,soil/rock type rain size etc.)
i
ft. � ft. s
4.Date Well(s)Completed: 21 Well ID# a ft. LA ft. M
Sa.Well o� I ca n• p�}-�
K C )s do e 1 ft. 51 J ft-
Facility/Owner Name Facility lD#(ifapplicable) o�J ft. ft. _mil
(OQQ M /�p�/� �p�y�� 2
U� 1 '1N,4J1.1 11R 'Dr 1 JllJd i 1 Y.� La 3 c�� ft. l-{a fL 1� c7Q�
rr n
Phy ical Address,City,and Zi C ft. ft. E 1, 2021
( 'N\I 1 1V,..,r�/a►, oil
_.I p'1 J�I 21.REMARKS
County JJri1 V�1� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p0 , 1 Ri1 �1 22.Certification:
3L4 D 5a/ a�1 5�o� N l O o, -lot. W f ri
6.Is(are)the well(s) ermanent or []ITemporary Signature of Ce0fied Well Com ctor f Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the nature ojthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L` `If SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@22000'and 2@100') construction to the following:
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Lp (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
i_ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: MU A RO SCJ�t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Dumv� l 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: l Amount: /"[ _ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016