GW1-2022-07477_Well Construction - GW1_20220810

W LLL l.V1.1011iu1.1Will 11.Ll.Vt(L 1 V VY-11 ror 1Dternai use unty: •
1.Well Contractor Information: / •
' 7-9/, i LI /4 AL? k e n c /fl/ .., =• ? ...... . . ":•.: ..,::...... .. ' 1
.�Ia.�wATSRzoNFs:'!:.••�;. �;: :;�.::_: �•.�:::::._a;.�.:::: _�._.
CRiP D FROM
WellCoatcactorName TO ESTICN
ft. ft' 3 Ub ,s�e.6,
(‘s'
e2a . / L/ — d- iL ft. db e a Sie/1 70a_L7 s r)NC'WeII Contractor CeRificationNumber YlWOUTER:CASING(fofmiiliasailiallts) ' R fibTER1ALFRO TO ' DIAMETER THICKNESSCh // JraS• T// C , LIY y.`t:
4-Iv •
Company Name
16:INNER`CAS GOR.TUBING:(Rauther'maleeldied46110)'•.:' it:t.',W ..:?.:c:'•:.'?:
2.Wei Construction Permit#: FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) fL ft, . in. '
3.Well Use(check well use): • ft. ft. in. •
Water Supply Well: ,,17.•SCREENs:,v: ..,.-"N?;u,Eiit'ar;:i.:.N 1i ..nz:'=-... ;is...' .ti satctiubt a5 f:•'•i:
FROM TO • • DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • °Municipal/Public ' • o re ft. in.
• Geothermal(Heating/Cooling Supply) °Residentisi Water Supply(single) R ht. •
Industrial/Commercial r3Residential Water Supply(shared) , ,._„ .
.�18GROUTt.'<. .... :t:isii .._ ::> ?•`�'''asi;T'. .�•'.u•'ci�is . ifiy��:.ir5i
gallon FROM TO MATERW, ~EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: oft. m.4 1-
Monitoring Recovery ft. ft. �C 9 ^. C r
Injection Well:
ft ft .
Aquiterltecharge IDGroundwaterRemediation :19SAND/GRAVELPACif(ifappllcable)>;X _:*•� ;'.ti :r=" :� "`1:,-:=hs , ::`:;;
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD P
Aquifer Test [ Stonnwater Drainage ft R
Experimental Technology • °Subsidence Control it ft.
Geothermal(Closed Loop) °Tracer 'lilaiRILLiNG LOG'(attachadditioniilliheetiifaia6iiily 1W.,::0V— rite::, ;;.tr
FROM TO DESCRIPTION(Mon twdaess,soLhoektype,etaroaia,Na)
.. Geothermal(Iieating/CoolingRetum) rtOther(explain under#21 Remarks) •6 to 6 Cr, n C a,-.4. A.4;au4
• 4.Date Well(s)Completed: '7:�Z—' welt ID# b f`' , se n' /j /"S/ (,cy,,,i cc d , I. _
5a.Well Lo •
cation: 1 q ft.
3••et' •, 4., ' ' p
ch.,,7,4 /fln».171j AM,er.(,0F•d"f'Sr Ct, 3o/y�-it. 7voft' _/%4✓,.: 7�,p't"'• �� c, 4'
4rdt)
FacilitylOwnerName - Facility lD#(if applicable) R' ft' � ° ' ' .
qC7 ' CoAill:I/ .1i k 66 I,c or A.4,4, ft. fL •pi)r, i 0 2022
•
Physical Address;City.and Zip 8 O I ft. fL
/9,-ry 21 RENARKS.r.'.W:ti:.':_<::::::..... iz„=:._.::c'j „a....`...,.r::�,,,(4. 4GS.3,,::
D:7.r.li 6 t-'‘-7
County .Parcel Identification No.(PIN) ( *-.%�e,-+• 6 p e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)r, f y 22.Certification: .
C-° �' �496 1 g'0, V3 Sot S63/ w ,mill , 7./2-22.
6.Is(are)the well(s)1rmanent or Temporary Sign aofCectified ell Contractor Date
By signing this form,I hereby cert(/y that the well(s)was(were)constructed in accordance 1
7 Is this a repair to an existing well: °Yes or glio with ISA NCAC 02C.0I00 or iSA NCAC 02C.0200 Well Construction Standards and that a
.' Ifthis isa repair,full out/mown well construction information and explain the nature of the copy ofthis record has been provided So the well owner.
repair under#21 remadasection or on the back ofthisform. •
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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
11
drilled: •
-�/ • SUBMITTAL INSTRUCTIONS
,/9.Total well depth below land surface: ' D Q (ft.) 24a.For All Wells: Submit this;form within 30 days of completion of well
For Multiple wells list alIdepths ijd�crent(example•3(�200'a trIMI00) construction to the following
10.Static water level below top of casing: l t7 (ft) Division of Water Resources,Information Processing Unit,• '
Ifwater level Is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617 ,` , .
11.Borehole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address ih 24a
� above,also submit one copy of this form within 30 days of completion of w it •
12.Well construction method: lf0 "I'e'^ construction to the following: •
(i.e.auger.rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 P. 1636 Mall Service Center,Raleigh,NC 276994636 •
13a.Yield(gpm) ��` Method of test: 4,r I,-U` 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit One'copy of this form-within 30 days of
13b.Disinfection type:(4/V r,•rI d-Amount: 4.9 eta I completion of well construction to the county health department of the county
where constructed. • .
•
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
.