GW1-2022-08095_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD a
This form can tie used for single or multiple wells wr
.1.Well Contractor Information-:--tf �
O�'1N 3.S Y cSlr2Qle I4.waTl:R•z o
FROM TO DESCRIPTION
Wall Contractor Nano ft. ft.
ft. ft.
NV Well Contractor Cenification\timber 35.OUTER CAS for mit[ti-evaetF iveFM R LFNER tf a i
FR0.�4 TO DL1h1Emat TH1CwT S MATERIAL ••1
V1 1 br'i 11 F t�1G1 rt. ft. I . - at I Pvc
Cempam'tamc - 16.ININERCASFN OR TV theriiizd'doseQ-loo
FROM TO I DIAMETER 7 1TH[CKtiFSS MATERIAL
2.Well Construction Permit#: ft• ft• in f
led all appkwh/r:well cnurtracvion permiar 11.e.Counp•,slate,I"I ianee.el-^./ ft. ft. ia• I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DTANIETER SLOTSi2E THICK�FESS MATERIAL
ft. ft. in.
OAgricultural ON unicipal/Public
OGeotherinal(I•Ieating/Cooling Supply) csidenual Water Supply(single) ft. ft.
Olndustria{iCommerclzi OResidennal Water Supply(shared) 18 GROLtT
{ it OM TO %1ATER[4,L E'1tPLAC£M&1TMErROD&AMOC'%T
{Olrrr¢auan re. a�"fa �'1X Y
Nou-Water Supply Well:
rt. te,
{❑lvionitoring CRecovery
Injection Well:
uAqulfer Recharge .-Groundwater Remediation 9..SANDIGRAVEL.PACt; if iIAL
FROM TO M.4TERIAL E\SPLACEMttYrglErftOD
i OAgwfer storage and Recovery OSalinity Barrier ft. ft.
{:_,Aquifer"Pest UStonnwater Drainage ft. ft.
(=Experimental Technology OSubsidence Control 2G.DRILLING LOG attach additional sheets if neeessary
0Geothermai(Ciused Loop) OTraeer 920M TO DESCRIP770N eaiorhardrfest saithaclt e.-ninrize,e:c.l
CGcothernsal(Heatin=Cooling Return) OOther(explain under 421 Remarks) fa ft.
ft. fr.
4.Date Welt(s)Completed: V� ft, ft.
i.1Yc1!Location: fr. ft.
f.
ft. fr.
iaalii).b%tnc;Va;+sc i� /� Facility to-fifapplicable)
ft. ft
Pt i 'caI Address.Cm,and Zip 2I.R£hCARKS
1[n3013G
C'ount%. P-6.1ldcruilieatioallo(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or deeima!degrees: 22.Certification:
(if troll field,one lationg is suffieien) rypp����'
Sisnaitire of Cenified%Veil Conttaclar- Date
6.Is(are)the well(s): epermanent or OTemporary yy siVung+his fnrin.1 hereby cerrdy 11ta1 the 61,en;rn,tttratlrrl rr,attrrrrkurre
e•ub iSA 4R:'A('!I?t'.(110t1 nr lS.A 4('rt['0$' 0?fill lYiil t buffer cimu.�anulnrrl5 rnnllhur a
7.is this a repair to an existing well: ❑Y!s or iVo caps of thre retnrd hat beau provided to the well n,r nee.
It ring 1a to reparr.hll am/klaxa»•ell crmrwr enrul rnformaniol and vrpkdn lift naalre tit the
repair under..-2/remark.•.vecitan or ai the back gfilds faun. 23.Site diagram or additional well details:
you may use the back of this page to provide additional%cell site details ar well V .
8.Number of wells constructed: construction details You may also attach additional pages if necessary
ForFor nurkrple n+lrcl1r:m outgo-ira/rr.rnp/r/t'a t//e 0141 F'w 11F,the.taivta crutarraellaN.1'ou tan
l it one/gear 24.Submittal Instructions- �-.•'
9.Total well depth below land surface: W / (ft.) 24a. For All Wells: Submit this form within 30 daYs of completion •: µµµµ.gib2
Ibra+rdul+le isellihrlall depdci Arlrllerent leroulph••3• 200,01111? a 111U'l construction to the following fa is 2�22
_ - -i- -- - ----- - Ur,
- 10.Static water level below top of casing: (ft,) Division of Water Quality,Information Processing r;�;;y 5�n : f • ..^-�
I!ua1,-r/r:vl r.Awe Laval.rc,e" 1617 Mall Service Center,Raleigh,NC 27699-1617 fit;±;
I 24b.For Inieetion Mena: In addition to sending the i'orm to the address in2•4,
11.Borehole diameter: (in.)
above, also submit a copy of this form within 30 days of cumolrnoi: of%veil
12.Well construction method:- ,-An far Ll construction to the following.
(le auger,rotary.cable.ducct push,ere.)
Division of Water Quakily-Onder'oround injection Control Program,
13.FOR WATER SitPPI.1'WELLS ONLY: 1636;Nail Service Center,Raleigh,NC 27699.1636
I t 24c,For Wate,_3¢pjrly&Gaitlterma!Wrfls: In addition to sending the form sa
13a.1'ictd A elfv% Method of test:�+sy' �1(��� )
(e'pm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1r Amount _ completion of Weil construction to the county health department of the county
where constructed.
Fomi OW-1 North Carolina Departmmt of Environment and Natural Resources-Division of Wafer Quality, tensed lai:2013