GW1-2022-02995_Well Construction - GW1_20220302

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
l yn r D'I -14.WATER ZONIN-
WellconttactorName PROM To DBSCRIMON
3 -A_A l D it. l /0 3
NC Well Conbuawrceeti8vatilmmi ber !65- ft. 7
V&_ U tCns[reo rmw wve oltLItVSR tltaDle
f p PROM To DIAMBTBR THICKNESS MATERIAL
Company Name In' -2( �t=
16 ROMRCASUVGORTOBING thervmdclosed400
2.well Construction Permit A C 1 W -Q E 7 31 D-•2V Z j FROM To I DIAMEM I TMCKNsss I MATMTAL
List all applicable well construction permits(i e.UIC,Count),,State,Yarianm etc.) ft. & i lit.
3.Well Use(checkwell rose): ft. ft.
vPater Supply well: 17.SCR]WH
PROM TO n siAT 9d28 THIC>OVHSS MATERIAL.
Agricultural 13M *a11Publio O fL EL in.
Geothermal(Heating/Cooling,Supply) Lla Zdentiai Water Supply(single) R.
Industrial/Commercial DResidential Water Supply(shared) 1&CROUT
Irll ation PROM TO I MATERIAL >$vmLACE 0NTMEMOD&AMOUNT
Non-Water Supply Well: R. &
__ Monitoring Recovery ft.
I1111ection well: ^
Aquifer Re6aW 13Gmundwabor Remediation
]9:SAND/GdtAYBL PACg P ltmlde
Aquifer Storage and Recovery DSalinity Barrier PROM I TO I MATERIAL. Mq ACEaIBNT METHOD
Aquifer Test OStoanwater Drainage IL
Experimental Technology 13Subsidence Contrul fa ft.
Geothermal(Closed Loop) DTracer 30.DRUIMG LOG attach additional sheets iP
Geothermal ajcati Coo lin Rctura Other( lain under#21 Remarks) PROM i TO DESCRIPT[ON color,bardn wiViecktym wain Elm ete4
19 & IL 49 C.fb Crd
4.Date Well(s)Completed:..!-Z Z well IDP ft' ft. (P Gj4
So./W��ellLocation:
f-� k"t!c tic
Facility/Owner Name FacllltyM# if applicable) ft ft' MAR 0 2 2022
Physical Address.City,and Zip
om,
It.
Q fi _ a ,-�.;•rm
blk- -C 0 77q y IS9 21.ARKS w 1
County Parcel Identification No.(PW)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrm:
(if well field,one lattlong is sufficient) 22.Cerliiicati
3 _i-9©9y N 7 �-/�1'S G� �3�� w -
6.Is(am)the well(s) erinallent or Temporary alga o or Date
�, By signing thin fors.I hereby ov?6 that the well(s)war(were)con coded In accordance
7.Is this a repair to an eaistiag well: My- or 61 with ISA NCAC 02C A100 or 15A NCAC 02C.02W WeH Construction Standards and that a
If this is a repair.fill out brown well constructon hpfbrmation and explain the nature of the ropy of this record has been provided to the well olJmer.
repair under 021 remarks section or on the back of lhisform.
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 walls Construction details-You may also attach additional pages if necessary.
drilled: yi T.IlrlgTRIICL[�TTC
P.Total well depth below land surface: Z 90 00 24a.For All We—Us Submit this form within 30 days of For multiple wells list all depths 1f dWerent(example-3Qa 200'and 2®1003 completion of well
construction to the following:
10.Static water level below top of casing: Z�i (ft.) Division of Water Resources,Information Procesft Unit,
If water level is above casing,use
//+" 1617 Mail Service Center,Raleigh,NC 27699.1617
It.Borehole diameter: t0 rlll.) 24b.For Infection 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: �n�+.�a-t construction to the follovn,n&
(Le auM may,cable,dotper,ere-)
Division of Water Resonrees,Underground Tgleetlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 2 16M Md Service Center,Raleigh,NC 2769XI636
13a.Yield(gpm) Method of test: d/in .��/fir^' 24c.For Waller Sowly&Iniecdon wells: In addition to sending the form to
the addresses) above, also submit one copy of this fotm within 30 days of
13b.Disinfection type: H 7 N Amounts f y o tA- c e-* completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Departasent ofEnvimnmentat Quality-Division of Wateritwonreea Revised 2-22 2016