GW1-2022-01119_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD F
This form can be used for single or multiple wells
I.Well CuntracttorrIInffoorAmaation: n fit
Oh'# a!S i O LILT �C I i� 11.WATER ZONES
FROM I TO DESCRlPT10\ �
Well Cuntractor\ante ft. ft.
i
\C'Well Coitt:actar Certification�umbtr IS,OUTER CASiXG for mtsld�taaed wells OR LINER tfa a)
FROM TO DIAMETER THIGINESS MATERIAL �r
= fr. f:. { in f r{ a� v
Company Nainc ACINNERCASIN OR Ti1BITI 'therbw elosed4w
f FROM TO MMETER to THICK�FSS MATERIAL
Wel
l ell Construction Permit#: y ft. ft.
/iw all appkwhlr well e•rinsirac•ilan perinitr h.e.Como-,Stare,I'artanc..eic./ ft. 8. in• !
3.Well Use(cheek well use): 17 SCREEN
��2ter Supply Well: FROM TO OTAhIETER SLOTSiZE THiCKNL55 MATERIAL
ft. fr.
OAgriculturai >C 4unicipal/Public
00eotherinal(Heating/Cooling Cooling Supply) esidenttal Water Supply single ft. ft.
(� � e PP5) PPY( 3 .
CrindustrialiCommercizi ❑Residential Water Supply(shared) GtROUT TO I 'NATERDLL I EmFLACEME\TMETItOD&AMOUNT
Clrrit:atiun ft. ft.ao
Nou-NVater Supply Well: rr. fe. ,
O!Nonaoring --Recovery
I Injection Well: ft. fL i
CAquifer Recharge --Groundwater Remediation 19..SAND/GRAVEL PACK lifautilicablel.
❑Aquiter Storzgc and Recovery OSalinity Barrier FROM ft. ft. MATEWAL EMPLAC'EMENTMrI'HOD
�Aquil'tr'i'cst OStonnwattr Drainaet
OExperimental Technology --Subsidence Control 20.DRILLING LOG attach additional sfteets ifneeessary
2Gcothermal(Closed Loop) --Tracer MOM TO DESCRIPTION rotor.hardnestsoit/rackI s.•rainsiu.tic.)
CGcothcrmal(Heating/Cooling Return) --Other(explain under 421 Remarks) fr fr.
4.Date Welt(s)Completed: One, LL,, 8)Q@ I ft. ft.
5.Wall Location: fr. ft. I
Fft. fr.
I:c N.ORule-uacr Unite Pac,liq 1D-rifapplicablej ft. ft.
1-rVIP.1 -PA 111•111 _ilf';I'
ft. fc
Ply sic dress.Cn),and Zip J 21.RENIAW
Holk EiiaQIQ4
C olnll%. Parcel identitieation No(PIN)
5b.Latitude and Lo*tude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(f,soli field,one latlong is suf6aen:)
N �V C ---
Sigrtature ofCcnified Well Contractor Datc
6.is(are)the weli(s): [i3Permanent or OTetnporary Ky.gwinig ihis,jnrin,l hereby certib-that the nei fy star Rego-)l'rat.,lratled ar aicconturrcc
1 n'Oli 1SA Ni'At'fl2f'.010u ni•13.4 vf'Ar'02t' 01l11l 1Neil('unrtrratrcnl.4ondorft unJ that
7.1s this a repair to an existing well: Dyes or 9'a cvgls yl diic mewd hos berg&ewided in the xr0 newer.
/(dif.,u a repair fell out karn,w wel/mastrucniui inforinarein and-plwo lire ntmrre if/the
retwir tinder:r31 rretarkv section or at;die back of thk(nrn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional wall sin details or uteri!'
R.Number of wells constructed: construction details You may also attach additional pages ifisecessary
hilt nwhiph,infection or nun-u-mvr.,upply a ells O,ti1.)':ref,the slime cr>ra<rrrrerinrr.►•on cyan
,ahnid iwv luau 24.Submittal Instructions:
9.Total well depth below)and surface: 305/ _(ft.) 24a. For All Weis: Submit this form within 30 days of completion of%tell
I•broatdniile%whN•b.0 all depih.,ddiflerenr(eworple.3•j 200'adand21F/fill') construction to tile following
10.Static water level below top of casing: —1 O (ft.) Division of Water Quality,Information Processing Unit,
ll unite h•.el i,uh++'r ca..mp.aa••' 1617 Mail Service Center,Raleigll,NC 27699•1617
/R 1
11.Borehole diameter: (in.)
24b. For Ink0on Wells: In addition to sending the form to the address in 24c
W
about, also submit a copy
}, of this form within 30 days of tumphruun of well12.Waif construction method: An�nr iJ construction to the following.
It c auger,rolar•.cable.dircci push,ere.)
Division of Rater QDRlity,Underround Injection C:ontro!Program,
13.F4R WATER S[tPPLI'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
4 �I ,'^- t 24c.For Water$uonly&C,eaLiscrmal N'eiis: In addition to sending the form to
13a.1•ield(gpm) tt h4ethod of test: c a'w�L_ the addresses) above, also submit one,copy of this form within 30 days of
13b.Disinfection type: L t' Amount:_ completion of we►l construction to the county health department of the county
where constructed.
Form OW-1 Korth Carolina DepArtment of Environment and Nnttuel RCSawet3-Divtsiort*MAW Quality' iteused tale 2013