GW1-2022-07884_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD&w 1) Print Form
�--�_ or Internal Use Only:
I.Well Contractor Information:
�..... t
1 .WATER ZONES
Well(C�onnttr�accttor.Name u 7�/� -'i-- OM TO DES_CRIPTION
==�51 r. L4:5 �* p• ft.
NC Well Contractor Certification Number R. ft.
I .OUTER CASING for multi-cased wells OR LINER if a Hcabla
� p (, �f"-' �(,x .'.�^ OM TO DIAMETER THICKNESS MATERIAL
Company Name I p• ft. org�ther,
J 1 INNER dASING`OR TUBING e�oural cl oaed 400
2.Well Construction Permit#: OM TO
List all applicable well construction permits(t.e.UIL;County,State,Variance,etc.) fit. ft. DIAMETER in. _THICKNESS MATERIAL..
3.Well Use(check well use): ft, ft, is -
Water Supply Well: 17,SCREEN
Agricultural 0MunicipaUPublic F ft. fit. in.OM TO - DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Cornmercial r ft• ft. in.
Residential Water Supply(shared) 18 GROUT
hTl aate FR M - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fit.
Monitoring Recovery r
Injection Well:
Aquifer Recharge E)Groundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PA_CK if a licable
FR M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control g, h
Geothermal(Closed Loop) Tracer 20. KILLING LOG attach additional sheets if neceasa
Geothermal(Heating/Cooling Coolie Return) Other(explain under#21 Remarks) ffiltM TO DESCRIPTION(color,hardeess,soil/rock e, rain size ete.)
fit. t fit.
4.Date Well(s)Completed:2 I f Well ID# fit. fit.
52.Well Location: ft. ft.
ft. fit.
Facility/Owner Name Facility 1D#(if applicable) ft* ft*
ft. fit.
)L"1101".
Physical Address,C iiand Zi - ft.
l_ ft.
.l 21. MARI{S
County f Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.i."krtification:
N W -Z 0U
FS-la
6.Is(are)the well(s) Permanent or Temporary i t of Ceres red Wcll ontractor Date
t
By Jplrning this form,I hereby cert6 that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Ro with ;A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationta=1-plain the nature of the caP gthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
—� SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface: clob and
For multiple wells list all depths (ft•) 24a. li'or All Wells: Submit this form within 30 days of completion of well
ifdlfferent(example-3@200' 2�I00')
construction to the following:
10.Static water level below top of casing: r
(fit.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.Fpr Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:-A I rz t 4 abovey also submit one copy of this form within 30 days of completion of well
(i.e.auger,rot construction to the following:
(� g rotary,cable,direct push,etc.) g
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: _ 24c.F r Water SuppLy&Injection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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