GW1-2022-07063_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only:
1.Well Contractor Information:
//r b�'»�1�J/✓h �Y``�% 14.WATER ZONES l I
Well Contractor Name FROM TO DESCRIPTION
NC\4bll Contractor Ccrtilication Number 15.OUTER CASING(for multi=cased wells)OR LINER(if ap licable)
TO DL\METER THICKNESS NA'rF.RI:\I.
ft. ft. in.
Cornpany Namc
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FRONT TO DIAMETER THICKNESS I MATER1
List all applicable n•ell cuns0•uc•riwr permits(i.e.UIC.Cattail-,State. Pariance,err.)
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO, DIAMETER SLOT SIZE THICKNESS NI\TERIAL
. _ grictdtitr.-i! _ - Munici drPublic - - ------- - r --
- - - - - pl ft. ft. --
Gec thermal(Heating'Cooling Supply) !Residential Water Supply(single) _
PIhditslriaiiCo`nmiercial Residential Water Supply(shared) 18.GROUT f
Irrigation FROM To ntnTERl.u. E n •m .r IowvT
Non-Water Supply Well: ft. ft. Utivtl
Ntonitoring ElItecovcry ft. ft.
Injection Well:
ft: ft. � 2 2022
Aquifer Recharge DGroundwater Remedialion 19.SAND/GRAVEL PACK(if app licable)
Aquifer Storage and Recovery ❑ISallnity Barr'i Cr FROM TO MATERIAL \ T r
'., AquilbrTest DiStormwalcrDrainage ft. ft. --
Experinhental'fechnolog) DSubsidenceC'ontrol
Gcothernhal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROaI TO DESCRIPTION(color,hardness,soillrock tY e, rain size,etc.
Geothermal(Heating/Cooling Retum) Other(explain under tt21 Remarks)
4.Date Wells)Completed: 2-Z Well ID# ��} f - o 2- Lp ft. ft. n/�
Sa.Well Location: n. C �j ft. �+�1�i,tjc'.(�Gyez(_Fa
v�� V/TP�Sv�v(ivvs !/Sr'-
r 1/ U 9!6A"G\�r'a?d( r C C A--
Foci/litelOtencr Name Facilily IDtl(ifapplicable) ft. ft. U ss^ 2 b✓C%I (/ C y(-rV 1'f r UC/�
'V'4241ei" p vC ap.k C' ft. ft.
fhvsnal Address.City.and Zip G-�t!��:5 O:UJ Ale_
2TL REMARKS /^ t
{bunt) Parcel Identification No.(PIN) fe O Iu
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'5h.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(if well field,onelat•long rs;nnicient) 7_6 O o,-FE­4 e i•✓ (�C�.yfd�Y J'�'
36 / 22,Certification:
—�-2_ --
6.15(are)the\s'ell(S) PernIDnent of TempOrtUry Signature of Certified Well Contractor w f)�Ie
By s/gnhkr this fin-in, l hereby eerti(i•that the wv!/!.t/waa (werrj ar;n'urrvd fir a.cnrr/am.,
7.Is this a repair to an existing well: 0Ye.s or MNo with/S.•I NCAC 02C'.0100 or/sa,\'C,4C 02C binn Well C'rnrsrr:r:•rirnr.Rn,rr/rrrdr arm that r.
11 this is a repai,,fill ou!knoan lief cnnslrra lirur hrJinnrutiuu and etp/ain the)nature u/thc copy of this record has been provided to the mW miner.
repair under 42 l renan{is,ecfhm„r on the barb(!/1h%s/arm.
23.Site diagram.or additional well details:
R.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional svc!l silt details or t)clr.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
-- - — SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ _(ft-) 24a. For All Wells: Subriiitithis form within 30 (lays of completion of well
Fnr•inulh/+Ir rrrli.r)isr et!!de/!!a rl dr/Irr'c•++t fetamplr`-?•ri.'i'r-''; .i'i,^l-G 1 �1
consUuclion to the following:
10.Static water level bclni, top of casing: _(ft. ''
-. �—� ) Division of Water Resources,Information Processing Unit,
!/nvrer h•rel s ahmr ra a;.e ,nr "a"/ 1617 Mail Service Center,Raleigh,NC 2709-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: In addition to sendu'ig the tLr;n t(.:%c uddre:s in,:__:
above, also submit one copy of this form within ?O days of completicii of%,ell
12.Well construction method: �t�.:✓t C construction to the following:
(i.e.auger.rotary,cable,direct posh.et,:.h
Division of Water Resources,!Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Nfail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Suimly& Iniec�ion Wells: In addition to sending the fonn to
the address(es) above, also stibtnit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction Ito the county health dep:ntnicni of the county
where constructed.
Form GW-1 North Carolina Depannment of Environmental Quality-Division of water Resoy tccs Revised 2-22-2016
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