GW1-2022-07243_Well Construction - GW1_20220805

iIPrint Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
yy ,
1.Well Contradoo�r Information: I
QI���P �•QC(J!J 14.WATER 70M f
wd6rizactorNa� FROM 70 DrSCRIMON!
ClT r 7� WO
II " c I
NC Well Certification Number I&O V
/ f��/�1 J}//�J ///I F ]SOUTERCA5ING formuld-caudsrelb ORLINER der e
Ml l✓�UfL Pi� S'eI/J� FROM TO DIAM6118t 'IHICIOVFSS MATERIAL
ce�sany xameff
S t�D tf G
n , �j�-a--lO��(d u.nvNeR c To oRruanvc eaaoo
2.Weil Constrvetion Pump#: 'W FROM TO DW14Ti3t iIDC7�iFs5 MKh7WL
Uu all applicable writ aomtn,ct1-P-miu(le.WC,Count',Smte,Variance.eta) ft ft �
3.well Use(cbecicwell use): m ft ;In.
Water Supply Well: FROM To DL4hWTER sr.Orsuz MECXNM MATERIAL
Agricultural QMunicipaMblic �(J ft R -I I e O {i f(rat) L,
Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft & fa
IndustriallCommercial Residential Water Supply(shared) IL GROUT
Irri •on FROM 90 MA7ERLAL EMnACEMENr METHOD&AMO1Nr
Noe-Water Supply Well: n f� dj` OQf
Monitoring Recovery ft IL
-lnjectio -
Aquifer Recharge [)Groundwater Remodiation
19.quifer Storage and Rwovery Salinity Barrier FROSANDI 1n) PACK MATERIAL EMPLA sttrrton
Aquifer Test [}StomtwaterDra(trege % D !e
Experimental Technology QSubsideaceConirol R R
Geothemtal(Closed Loop) QTracer 20.DRILL 1NC LOG attach addidanat ibeeta if
- Geothermal eatin Conlin Return) Other( lain order tY21 Remarks) FROM 70 nssaarPrtox mar adVmdr Ke
R ft r D S'6t`
4.Date Well(s)Completed: well WN `3 n' 117 (L A
5s.we I ocstloD: - f % Np it e,q
'� 1'b'0 a; g
Facility! Name Facelity IDa(ff�likable) 19 D R D& 0.0(A •- INGM
D �i �ti' �l�eti d Ze II/G,�.Z % ftPhy6 n n
CijX Ind Zip IL 1 2 AUG
21.RDKARRS -
.�v ���r!r��I tareel Identification No.(PIN) iftiorma:ien nrcneG siatg Ur9t
e
5b.latitude and longitude in degriteslminutestsecomds or decimal degrees:
(ifwellficId,am Id/long issufficient) 2MAV-d
eadot4,
N W2-
6.Is(are)the well(olapermanent or E]Tempornry S ofCerdfied Well Contactor I I Date
By signing this form,h hereby cerrtfy drat the wells)was(were)cambuttrd in accordance
7.Is this a repair to-on etlsting well: Dyes or ©No with 15ANCAC 02C.0100 or 15A NCAC;02C.0200 Well Conscuarlon SSmdan*and that a
11this b a repair,fill out Imam well corairriciffin inJornzadon and Wain the"acute ofthe L1opy ol/htr recordhas beenproyW i to dw well owner.
repair wider ii21 remarb section or on ale back ofthis form 23.Site diagram or additional well details:
8.For GeoprobcfDPT or Closed-Loop Geothermal Wills having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: a�d (n-) 249. For All Wells: Submit this form within 30 days of completion of well
For rmtltiple wells fit all depths ifdlfferent(example.3 00'and 2Q100) construction to the following:
10.Static water level below top of easing: G- (1L) Division of Water Resources,Information Processing Unit,
lfxater level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter 0 (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: d construction to the following:
(i.&aaga,rotary.cable,dh-push;etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) cl Method of test: ac F 24a For Water Sumaly&iniedion Wells: in addition to sending the form to
a5 the address(es) above, also submit one copy of this form within 30 days of
13b.DIshiredion type: Amount: ' J completion of well construction to the county health deparunent of the county
where constructed. i
Form OW-1 North Carolina Department ofFavironmeatal Quality-Division of Water Resources Revised 2-M-2016
I