GW1-2022-08309_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Inffoormati/on: /
.1 dhn �i /f4 L Kion di�� :14:+WATER ZONES`.' r:: s;'
We1lCoahactorName
FROM TO DESCRIPri i
it. M
_A o0
fL ft. I �
NC Well Contractor Certification Number
s1580UTER:CASING toemuIti-aaie'dwells ORLINER its"'liceblr
y'� CC��I YjJQS y/!C FROM TO DIAhWTER TLUCENESS ATATERUL^
CompaayName
`.1VIN19R'CASING ORTUBING.'eatlie?mnl el&R.To-o' '
2.Well Construction Permit#: FROM _ To DIAMETER I TMCKNESS �I MATERIAL ~.
List all applicable well canstruction permits(Le.UIC,County,State,rarlane4 ete.) ft. M in.
3.Well Use(checkwell use): it, ft. in.
Water Supply Well: A7.;SCREENs2s:
bIi014f TO:..r DLUYTEI'ER SLOT SIZE .•„TffiC[QHFSS •• blATERiAL•••::
..Agricultural E3Mun1cipal/Publfc U fL tL fa.
_ Geothermal(Heating/Cmoling Supply) E3Residential Water Supply(single) ft ft
'
htdustrial/Commercial ✓residential Water Supply(shared)
::185GROUT1-sS:? �:'t,t"•.•3s?S.r�;:<::: _ '::'s.•:' i`"•S�'::'i;a::.'.�'-.-.sid :rt7:.s�8`-;`.•
. Irii ation FROM TO ...MATERIAL•'•• �.EW1ACE5HMTMETHOD&AMOUNT
Non-Water Supply Well: fa ft
Monitoring r3Recovery fL it:
Injection Well:
........ . ..
fL R - -
AquiferRecharge OGroundwaterRemediation
:°:19"•SANDIGRAVEt:PAGK d'a•...lieable?`�' :5�7e�E•::�� �i%�;: : ?:c?'r::;,r�.'.:::5'E6
. Aquifer Storage and Recovery OSalinityBarrier FROM I TO MATERIAL EMPLACEDIENTMETHOD
-_ AquiferTest ElStormwaterDrainage fL ft
Expesilnental.Technology 13SubsidenceControl ft ft
Geothermal(Closed Loop) [3Tiacer 720.DRILLINGLOG attachaddiHcnal-ibeatfitaeease
Geothermal(Heating(CoolingRetum) nOther(explain under#21 Rernaft) FROM TO DFSCRWnON cotar bncdaemsourmek xb=ur-j"
O fL ft-
4.Date Wells)Completed'Z_5 Wen M# D fL ft -e_
5a.Well Location: rJ ft too R'
Uo M � a fL .
Fam7iry/OwnerName _ Facility MN(ifapplicable) 7 rs c fL 8,00 fL ` ;� e.: r
am o2u � Ltd Ra�r� e? 17 e, 27/'/y fL m - � e� .� •r,�a
PhysicalAddnss.City,andVp fL fL
County Panel IdentificationNo.(PIN)
Sb.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlongissufficient) 22.Certification: P l "� -�` "t"•++ � 1Yks��'�i
d
tJl•1!V(`
S �/ (o.1'S�f Pm N 7s 35; �9zjy99' tr
6.Is(are)the well(s) rmanent or OTemporary
Si§i'ztmcoFCctHficdWcllConftactor Date
By signing this form,I hereby eerttry that the wells)was(were)constructed In accordance
7.Is tbls a repair to an existing well: E3Yes or e�P16 rvlrh ISANCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Srandardsand that a
IfthtsIsarepalrjlforttknmvn Well ConstructionWormation and mplafn the natureofthe copy ofdSsrecardhasbeenproddedto the wellmvner.
repair under#2I remarkssection or an the backofthtsform. 23.Site diagram or additional Well details:
S.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �S 4 (ft) TAa.For All Wells: Submit this form within 30 days of completion of well
Formrrhlpre wells fbt all depths y'd8erent(-ample-3@200'and l a@100) construction to the following•
10.Static water level below top of casing: y D (ft) Division of Water Resources,Information Processing Unit,
lfwarerlevells above casrn&use
+" .1617Mai1ServiceCenter,Raleigh,NC276991617
11.Borehole diameter. Ca. �� ` (in) 24b:For Infection Wells: In addition to sending the form to the address is 24a
12.Well construction method: c-d T,c"V above;also submit one copy of this form within 30 days of completion*of well
(La auger.rotary,cable.dkcctpuA,etc j ' - construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ) f 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm)3 Aerh Method of test: •1 / 24c-For Water Sunniv&Infection Wells: In addition to sending the form to
Q the address(es) ahovc; also submit one-copy of this form within 30 days of
13b.Disinfection type<A u r.A Amount:L1(f completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEavuoomental Quality-Division of WaterResoumces Revised 2 22 2016