GW1-2022-07317_Well Construction - GW1_20220809

WELL C0NRTRUCTI®1,,t RAC®RID d
This form can be used for single or multiple wells For internal Use ONLY: I
1.we Contractor Information:
Well Contractor Name FROM TO DESCRLPTION
S ft. ft % I
e 6-
IS. tt. ft r
NC Well Contractor Certification Number OUTER CASING for multi-eased wells OR LINER if a licable
Y 1 . 1 a► FROM TO DIAMETER THICKNESS MATERIAL
1r-, 11` n(r fa Zft
in.
r�•r;:ame 1 16.INNER CASING OR TUBING eothermaI elosed-loo
2.Well Construction Permit#:__ FROM TO DIAMETER THICKNESs MATERIAL
List all applicable well permits(i.e County,State,Variance,Injection,etc.) ft ft m
3.Well Use(check well use): ft % in.
Water Snppiy Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑lMunicipal/Pablic % ft in.
❑Geothermal(Reating(Cooling Supply) Supply(single)rdential Water Su 1 ft ft in.
❑IndushiaUCommercia! ❑Residential Water Supply(shared) I&GROIIT
❑11Ti atIOII FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft ft
Injection Well: f< Z t
❑Aquifer Recharge ❑GroandwaterRemediation 19..SAND/GRAVEL PACK ,fa li 6Ie
❑Aquifer Storage and Recovery ❑Salinity Barrier Mom To MATERML EIVIPf ACELYIENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft &
❑Geothermal(Closed Loop) ❑Tracer 20.DRII.LiNG LOG ariac bad ditional sheets if aecess
FROM TO DESCRLPTION color,hardy aoiUrock S
❑Geothermal(lieating/COoling Return) 00ther(explain under#21 Remarks) (� ft ft
Uc
4.Date WeU(s)Completed: l� ft ft
5a.Well Location: ft OR—C) WdJ f
c 73e�r, � w �Q z ft-
Facility/Owner
Name Facility 1D#(if applicable)
000' ft
e T'a ��L�/+�jiU �� 1� �I ft ft
ft
Physical ddtess,City,and Zip ft.
_n t7 21:BEMARl(S .. 022
County — < ;.>i, ,fit:
Parcel Identification No.(PIN) ''� '''
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
94 .6 I8319� N_79 •C) ? 22- 2 w JtA1,
P
6•Is(are)the well(s): [ iu[
anent or ❑Temporary 0.buae or Uertitied Well Contractor Date �J
By signing this form,1 hereby cert#y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or akw/ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
you can
8.Number of 1 You may use the back of this page to provide additional well site details or well
For multiple injection or non-water supply
constructed:pply wells ON LY with the same construction details. You may also attach additional pages if necessary.
construchon,
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: -2— 9.0 (ft.) 24a. For AIL Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd0rerent(example-3@200•and 2U 00 1 construction to the following:
10.Static water level below top of casing:
If water level is above casing,use"+ (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells ONLY: 16 addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
L.Well construction method, , l� r„�.�„ ,. �A construction to the following:(i.e.auger,rotary,cable,direct push,etc. � �
Division of Water Resources Unde FOR WATER SUPPLY WELLS ONLY: rground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c•F_or Water Suply &Injection Wells:
` 1,4 La Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county healt i department of the county where
constructed.
Form OW-1 �
North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013