GW1-2021-02579_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only.
1.Well Contractor Information:.
5:7i., t,t i`
WeQContractorName FROM O DESCRIPTICK
3`/ to '7 0 &
fa ft.
NC Well Contractor Certification Number '419::OUTER.CASING formWtteated.aells OR'LINER PS"Iteable :ii:'„;ic:s:•:'>s:zei`
FROM TO DJAMETER1 THiCKNESS I MA�T�ERW,
r i S n r �ta f 1 tr. 1 19
in. '�r ✓oL 1 1/
Company Name led
NMUL CASING OR:T
/
2.Well Construction Permit#: e d 12019 FROM - TO DIAMETER THiCIQVESS pfpr c asar.
List all applicable ivell construction permits(Le.WC County,State,Varlanca etc.) � it in.
3.Well Use(check well use): R' fL In.
Water Supply Well: AW SCREE N-cis> ' >+a:�;<"o-•� ;'G� ::i::_,aS:�,= ;�-� ';i =:
FROM TO„i >DIAMETER f SLOrSITE':• 17HCSNESS :MATERIAL
Agricultural 13MunicipaUPublie. 0 R R In.
Geothetmal.(Heating/Cooling Supply) [3Residential Water Supply(slope) ft ft. In.
IndustriallCom mercial [)Residential Water Supply(shared) :pis:cROtTr:A,-`Ilri lion FROM TO ,TERiAL t:,EMPIACEMENT MEIYOD&AMOUNT'
Non-Water Supply Well: II' ft v.
Monitoring Recovery tt;
Injection Well:. it
Aq ft
uifer Recharge OGroundwater Reinediation
49:�SAND/GRAVF.GPACK 'a'_.IIe663E'�'°`� �`�" ;;:s:`;':n�s";•'�:"iCr;:'� i�- °,;'
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATEIWL EMPLACF1+fENTMETHOD
AquiferTest [3Stormwater Drainage &
Experimental Technology Subsidence Control ft S
Geothermal(Closed ioop) EiTracer E20:'DRPLLiNGIAG aetaetiiddiHdidibiaefa :SSyz:;;E:3_°- °.
Geothermal(Hearin ooling Rom) Other( lain under#21 Remazks). pd.Of
TO DESCRIP TfON toter Ira:d suditetek I • ere
4.Date Weff(s)Completed: -� — -;•/WellID# 02
R' G5a.Well Location: Sftdft-
Faciity/OwnerName - Facility M#(ifapplicable) I
e e tt. t
�—
Physicel Address,City,and Zip ft. ft
County Parcel identificationNo.(PIN) O
5b.Latitude and longitude in degrees/minutes/seconds.or decimal degrees:
(ifwell field,one latllong is sufttclent) 22.Certification:
3 if�3 N 1,d 13, 3 5/� w ✓ r��te'-T
6.Is(are)the well(s)0Permanent or Temporary �i atoteofCecti Wert Contractor
� By signing this form,1 hereby certify that the well(s)was(we're)constructed In accordance
7.Is this a repair to an existing weil: r3Yes or FE wilh 15A NCAC 01C.0100,or lSA NCAC 02C.0100 WeB Construction Standards and that a
if&&is a repair,fill outknown wellconstruction Information and explain the nature ofthe copyofth[srecordhmbeenprovidedto the we//mvncr.
repair under 021 remarks section or on tka back ofthis 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"page to provide ad�aw ° o ell
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages�ne
drilled: SUBMITTAL INSTRUCTIONS NOV 18 2'021
9.Total well depth below land surface: /J O 00 24a.For All Wells: Submit this form within 30 con letion of well
For multiple wells list all depths ljdifferent(e-Wle-2 100•amd 2@100) construction to the following: SEC ION
10.3tatic water level below to of casing: [[//' �f�OR11�i �Ii�G UNI`r
p ing: 4r, (110 Division of Water Resources,Information ON
lfwater level B above cwlny,use"+", rr 7a 1 1617 Mail Service Center,RalefpJy NC 27699-1617
11.Borehole diameter: (in.) ,, e e -_...
70 0� 9oa 246.For Infection Wells In addition to sending the fora to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y h 4.4-V construction to the following.
(Le.auger,rotary.cable,data push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
r
13a.Yield(gpm) 1A 0 q0 M Method of test: 24c.For Water SuoDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:r;���Y :1 V Amount: completion of well construction to the county health department of the county
,.2 I where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources `-Revised 2 22 2016
I