GW1-2022-06894_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
6,4N LV 1 /Y\/J cif l\ 14.WATER ZONES I I
Well Contractor Name FROM TO DESCRIPTION t
CN ft. 5 ft. i
7d J-0
NC Well Contractor CertificationNumber IS.OUTER CASING for multi-case&iv6IIs)OR LINER its livable)
C/,t �C �� Q Y L''//• „� L �� r•ItoM nLtMF:rtat TIUCKNESN MATr.RLu.
Company Nam I'�c J
16.INNER CASING OR TUBING isothermal closed-loop)
2.WCII Construction Permit#: FROM TO DIAME ER� TUICKNESS MATERIAL
List all applicable hell ronstnu-tion pernnis(i.e.LOC.C'ounrr•Slate.Variance.c•ic.)
3.Well Use(check well use):
ft. ft.
(y in.
Water Supply Well: 17.SCREEN I
FROM 1.0 DL+A1r.TERI, SLOT SIZE THICKNESS iNtATERI:+L
Agricultural Municipal/Public ft. n.
Geothermal(Flcatiru/Cooling Supply) DResidential Water Supply(single) ft. fl.
lndtistrial/Commercial Residential\Nate).Supply(shared)
18.GROUT f
lrri gation FROM 1 O MATERIAL EMPLACEMENT METHOD&ANIOUNT
Non-Water Supply Well: ft. ff.
tZINIonitorhiL ❑Recovery ft. ft.
injection Well:
ft. ft. I.
Aquifer Recharge QGrMtndwater Reinediatioll
19.SAND/GRAVEL PACK(if a licuble)
Aquifer Storage and Recovery D)Salinity Farrier FROM 'rO MATERIAL ENIPLACENIENT METHOD
Aquifer Test QlStonnwater Drainage
Experimental Technology DiSubsidence Control
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach additional sheets if necessary
FROM To DESCRI I''1'I ON Icolor.hardnev%.snilfmck t+ e,grain sae.etc.)
Geothermal(lleating/Cooling Return) Other(explain under 4-1 Remarks) fc, ft. " + 6:-C,C V/111 Sal-
4.Date Well(s)Completed: 22__.LZ. Well 1D# w �/ 2 L ft. Z) Iry .
• ��
Sa.Well Location:
ll / 3 �� ft, It.
Facility/Owner
Naime ! J 1 facility Ifln(ifupplicable)
7qg 7 691,0
; `
Physical:Address,City,and Zip
��� y21^.RE3fARKS
/EM L-ael' 0.)JCA.J<�t.'t-rf.°ramGL1G;';a•c' :`: `. t ",1�' (�C
1 County Parcel[dent ilication No•(PINE v
ib.Latitude and longitude in(degrees/minutes/seconds or decimal degrees:
r+e t/7— rev(7`v,t=F�i++r
(if well field,one lal long is sufficient) 22.Certification:
3S- 3.�72635 N — �.- W—i J97Z �f� � 2V -2—a?
6.Is(are)the well(s)OIPermanent or [B•Temporary Signature of Certified Well Contractor 1 !— Date
(iv signing lilts f n-ni,I let ehr vertifi•that the wellfsl.was (were)consirurted in ucc•urdance
7.Is this a repair to an existing well: E]Yes or [ONo irith 15.l A'CIC 111C.1111111 ur I i;l,VC'AC'fl?C.0101i)fell Cunsnvctian Standards and ilia(o
y this is a repair.fill snit known vrll c•nnsavction inlorniumm and crpletin the nuturc of"the, rapv o/this record/ace brc•n provided ici'.thr ire\!owner.
repair under 421 remarks section or un the bark ul fhis(urn. I
23.Site diagram or additional troll details:
S.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page tIt provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may als i attach additional pages ifnecessary.
drilled: SUBMI.1"rm.iNSTRUCTiONSi
9.Total well depth below land surfacer (ft.) '
p 24a. For :\Il 'tells: Submit this furor within 30 clays of completion of well
fir nudpj,le hellos list all depilis if'di(lercnl(example-3k(200'anrrdd�'4g100') construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resou roes,Information Processing Unit,
1f will").level m above rccsii!e.ass"r" 1617 Mail Service Censer,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For lniection Wells: In ad(itton to sending the form to the address in 24a
CC above,also submit one copy of 1 iic form within 30 days of completion of well
12.Well construction method: J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEELS ONLY: 1636 Mail Service`Crenter,Raleigh,NC 27699-1636
13a.field(gpm) Method of test: 24c.For Water Sunni'& iniectioI" Wells: In addition to sending the form to
the addrcsstes) above, also subi�its one copy of this form within 30 days of
13b.Disinfection type: Amount: construction completion of well constction�to the county health department of the county
where constructed.
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Form OW-1 North Carolina Department of linvironmmital Cluahtt•Di%ision of Water Re'sourcL Re%ised 2-2-2016
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