GW1-2022-07918_Well Construction - GW1_20220823

11/1Il I
WELL CONSTRUCTION RECORD(CW-1) For Intemel Use Only.
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1.Well Contractor Information:
' D O�V i Cook .14a WATER ZONn f
1 We11Cor+uactorName - PROM TO DGSCRrPIlON
449� - A L ft.
N(C�Wcll Culnrador Cc`A.ificalion Numberkwek15. UIR CA-SINGorm R
LIBER MU bit)
11�V3 C�O11 S ��Ut ��1�1i FROM ft. TO f!. DIAMETER(� 77UCKMESS I MKIICWAL
O C LJt✓
Company Nnum I&INNER CASING OIt L MMG elmed i
2.Well Construction Permit fl FROM TYr DIAMEMR imCKWESS MATERIAL
List all appllrahle tuellrnaaructian pe mire(Le.U1C,Court':Stan,Variance;etc.) ft• fL id
3.Well Use(ehecie well arse): ft.
[Musirial/Commercial
Sn 1 Well: 1%SCRE M
PPY FROM TO DL4mrrxR SLOTSV.E TMCKNM MATERIAL
[] tpaUAlbtic t7>ti . Iw J se- /-ermal(Heating/Cooling Supply) Residential Water Supply(single) fL rL ;n.
ORcsidential Water Supply(shared) M GRObon FROM TO T F.AM ACOMENT METHOD&AMOUNT
Non-Water Supply Well: ft d n r
Monitoring Recovery
Nee on Well: ft. rL
Aquifer RechMe riGroundwater Remediation
19 SAItD1GRAVEI.PACK k
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERrAI. I EMnACEME Nr MUMOD
Aquifer Test E)Suxmwatal?rainage ft' eft'
Expetitnental Technology OSubsidence(•.tmtrol ft. ft-
Oeothermal(ClosedLoop) O'iraeer 20.1112II.IJNGLOG tllarkat&MMEalabMftIf
Geothermal eatin lia Return) Othcr(explain under#21 Remarks FROM DTtiCR1>'7ION gg em
Q/ ft. ft. sy w ., B• .r.
4.Date Well(s)Completed: Well IDN' G fI. L� M
' J .y
E•
�,Well
Location:
S.b Y11Y U L R'
Facility/Owa� Facility IDII(ifapplicahk) -
R ft.
P i al Address,City,aW Zip
a n.
21.REMARIGS' '
County Parcel ldeaaifteatioo No.(PIN)
Sb.Latitude and longitude in degrees/minotea/sesonds or decimal degrees:
(if well field,one lattlong is sufficient) 2L Certification:
N W
6.Is(ari)tlae we-11(a) Permanent - or OTelumrary Si ofCtatificd Wcll Contractor Date!
By aigniag this form,1 hereby ovlify that the wells)coal(cone)constructed in aarardaar
7.is thb a repair to an eilsting well: OYes or !o u*h 15A NCAC 02t:.0100 or f SA NCAC 02C.02110 WcH Construsalon Stamianh and that
lfthir it a repair,fdl ova blown wdl ca truction information and explain the no rum ofAc copy ofthlr mard has bern provided to the well owner
repair under 021 remarks serrion or on the back of ihisfom. 23.Site diagram or additional well details:
You may use the back of thus page to provide additional well site details or we.
g.For Geoprobe/DPT or Closed-Loop Geotbermat Wells having the same �•
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells' consinlctiou delude. You may also attach additional pages if necessary.
drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` / 0 Y •) 24a, For Afi 3WI: Submit this font within 30 days of completion of we
For multiple wrAr llrt all depths Ifdi(ferent(trample-3@200'and 2@1001 construction to thofo)lowing:j
10.Made water level below top of casing: J Al A) r D1vlil;ft bf Water Rm rccj*bforgatlon Processing Unit,
lfwaterlevdb above cwfng•we'+ 1617 Mall'i4 ire Cenber,,*gI*kNC 276W1617
11.Borebole diameter. (In) 240.Ear Intection Wells: In adilifion to sending the form to the address in 24
JaboYq also substiiVhDe copy;of itfs form within 30 days of completion of wo
12.WeII construction method: C/ constnwtion to the,'following:
(Le.auger.rotary,cable.direct push,ete.)
Division of water Rea ctrees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servloe Center.Ralelgh,NC 27699-1636
13a.Yield(gpm) Metbod of test: '� 24e.For Water SuDDIy&I i
� Iesdon Wells: 1n addition to sending the form t
the addrtss(es) above, also submit one copy of this form within 30 days c
13b.Disinfection tune: Amount Z-- completion of well construction to the county health department of the count
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