GW1-2021-02615_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor
/Infa ati an*
a V rit/rl m.-WATER`ZONES L.;. .. :.
Well Contractor Name FROM TO DESCRIPTION
nn R. 0.
NC Well Con ctor Certification Numb IS.:OU TER.CASING'tor.;mulN=sased`we!s 'pRf1iINER±1P.a lltnible
�,f FROM TO DIAMF,I•F.R THICKNESS MATERIAL
lll�i�Gl ''1 -S ll V VV 1 ft. ft. d,jZ�r in. 5,0 ( G
Company Name
16::INNI KUSING.OR-T ING- eotbirim.ileOdsed=loo
2.Well Construction Permit It: �) _ v f FROM TO DIAMETER I THICKNESS MAITRUL
List all applicable well cansiruction permits(i.e.UIC Coanry,State,Variance,etc.) It.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN•. :. -:;: -.. -.
FROM TO DIAMETER SLOT SI7.E THICKNESS MATERIAL
Agricultural ©Municipal/Public ft• ft. to.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) n• ft. la.
Industrial/Commercial DResidential Water Supply(shared) 18:.GROI)T
Irri ation FROM TO MATERIAL EMPI.ACEME METHOD&AMOU11'T
Non-Water Supply Well: D ft. a ft. Q p 1 5
Monitoring Recovery, ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.,SAND/GRAYEVPAC (fa''Iicablo
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRIId3 VQ OCi.attach.odilltlotial:stieits=lf:peeesea
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soll/rock type, rain sizo eta
D ft'6. rt.
4.Date Well(s)Completed: '�—Z• Well ID# [t. 5ft.
Sn.Well Location: fir R'
e_r O ft. tt.
Facility/Owner Name Facility ID#(ifapplicable) R• ft.
4� 'J D ik 5 ffif alp zya� f. ft.
Physics d1dressss, ,ity and Zi, ps J ft. ft. \v�
r-To r 2Y..REMARKS c,�
c County Parcel Identification No.(PIN) 22f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: c
(ifwell field,one lat/long is sufficient) 22.Certification: Ne0
35 474i? N --YJ1 9799 W
6.Is(are)the weU(s)1Permanent or Temporary signature of Certified Well Contract r Date
By signing this form,I hereby certify that the n+ell(s)nws(were)com inicted in accordance
7.Is this a repair to an existing well: ElYes or X)No with 1SA NCAC 02C.0100 or ISA NCAC 01C.0100 Meli Consa•uctlon Standards and that a
If this is a repah;fill oul lmotm well construction ht(ormation and explain the nature of the copy of tits record has been provided to the u+ell owner,
repair emder 1121 remarks section a•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 t GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessa►y.
drilled: ,,II SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `f (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For anluple wells list all depths 1f dVerent(example-3@200'annd 2@100) construction to the following:
10..Static water level below top of casing: (e (ft.) Division of Water Resources,Information Processing Unit,
If nester level is above casing,use"+/ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: tU (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: !�-� �� a�� 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: t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: 4U r 24c.For Water Supply&Injection 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: '�I C,Y"I)Ie, Amount: lL 5 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