GW1-2022-09344_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-D For Intemal Use Only:
1.wen
-+CD11tractor In%rination:
J GILS a J\ ( Y `,&WATER ZONES
FROM TO DESCRWr[ON
Well ComlactorName I
,�-7x C 13LV ft. tip •
NC Well Contractor Certification Number e
�A��1 /� n IScODTFdt.CASING' "-loairttt - R T cable
V v U i t'r 7 IJL�( S t •�j, FROM R• TO DIAMCM In. TIfTCBN�3 MATERIAL
u6A
CompaayName 16.INN6RCASINGORTOBfNG:( , .f
elosed400
2.Well Construction Permit : FROM TO I DIAMerBR THICKNESS I MATERIAL
List all applicable well construction permits(ie.VIC,County.State,variance.etc.) ft• ft• 11'
3.Well Use(check well use): & & In,
Water Supply Well: 37.SCREEN
FROM TO DIAM M SLOTS= THICKNESS MATERIAL
Agricultural _ cipaMblic G it. ft. tm
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. fL "a.Industrial/Commercial DResidemial Water Supply(shared) &GROUT
Iffi ation FROM7O MATBRI EMPLACE MUMOD&"otm
Non-Water Supply Well: ft• ft. p
Monitoring Recovery ft. fL
lWeetlon Well: ft. ft.
Aquifer'Recharge nGroundwater Remediation ly.SAND/GitAVEL PACK:[ llcetiie
Aquifer Storage and Recovery E3Sallnity Barrier FROM To MATERTAr. EMFLACENNn11VTMEMOD
Aquifer Test [3 Stormwater Drainage ft• ft-
Experimental Technology Subsidence Control ft.Go
(Closed Loop) Tracer 20.DRII.LING:I.OG attach additional shears if
Geothermal(Heatin Coolin Return _ Other lain under#21 Remarks FROM TO DESCRIPTION(color hardness,solUn)ck eta
tt. ft.
4.Date Well(s)Completed: `r I ✓ "Well W# ft. ft.
Sa.wen
li L Yew tJi r f; ft. Ft. Q zozz
Facility/Owner Name Facility M4(if applicable)Uni) ft. ft. t _.- r r *•
S t ( rn,t/ ft. ft
Physical Address,Cityand Zip
!�G172`
( Cl w�i C f '21.'REMARKS
County , Paroel IdeScation No.(PIN) (
,
5b.Latitude and longitude in degrees/rainutes/seconds or decimal degrees:
(if welj field•one fatllon is sufficient) 22.Certification.
t . NZ I" Ili a,3(0 6,P
6.Is(are)the well(s) Permanent or 01empofary Signa of Certified Well Contractor VrDate
� liy signing this form,I hereby certifythat .11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: tY}� or E3No with 15ANCAC 02C.0100 of 15A NCAC 02C.0200 Well Construction Standards and that a
#this is a repair,Jill oat known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled-, ii SUBM=AL INSFRIICTIONS
9.Total well depth below land surface: l (R.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths 1f different(exmnple-3®200'and 22@1001 construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" t 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: '� (in) 24b.For Injectiom Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rC CLl construction to the following.
(i.e.auger.rotary,cable,direct push,eta)
Division of Water Resources,Underground Weedon Control Program,
FOR WATER SUPPLY WELLS ONLY: ,I _ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: V 24c.For Water Snapiy&Injection 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., H Amount: n V A Gr S completion of well constructionl to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water ResourcesC Revised 2-22 2016
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