GW1-2022-09352_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1. I
Welllf C.,ContracContractorInformation;
I�l L c —,A "14.WATM ZONES -
Well Contractor Name FROM TO DESCRIPTION
qS 7 C 7OR- ? f. i Pm
Ir
NC Well Contractor Certification Number 9oft- 1 l a GI PM
_ I&GU1EKCASIlYC`' iiltt W OH7;IiV6R" eaDre
1n) PTE )�� j1 . f FROM TO DiAMSCBR TffiCKNFSS MATERIAL
w 1J J /V\ r fk ft: in.
Company Name I6.INNER CASING OR Tl?BING ermel closed-1ao
2.Well Construction Permit#: FROM TO DUMETER I THICKNESS I MATERIAL
List aft applicable well construction permlis r e.UiC,County.State.Variance,erc.) ft• d q in, 'c.� c) VC
3.Well Use(check well use): ft. ft• rn•
water Supply Well: 17.SCRIKEN.
FROM TO DTAME'rER SLOTSEM THICKNESS MATERIAL.
Agricultural DMunicipaMbiic 0 ft. & in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g, g,
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation - FROM TO MATERIAL EMPLACEMWrMffK0D&AM0UNT
Non-Water Supply Well: D IF to O 1�.f. Y R O lbs
t.Monitoring Recovery M f
Nection Well:
Aquifer'Reeharge DGroundwaterRemediation ft. ft.
.
19.SANDIGRAVEI.PACIC >f.• llcable
Aquifer Storage and Recovery DSalinity Barrier FROM I To MATERIAL EMPLACEM MMEPHOD
Aquifer Test [3 Stormwater Drainage ft ti•
Experimental Technology rISubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.D LOG atmch additional sheets ifn
Geothermal(Hearin Cooling Return) _ Other explain under#21 Remarks) FROM ft. ft.
To DESCRIPTION(color,hardness,aan/rait etc
4.Date Well(s)Completed: IS-2 I'Well ID# R' O•
Sa.Well Location: ' M
ft. _
Facility/Owner Name Facility MA(if applicable) fL ft. t4.
u R14A C''r 2�r ft. ft.
Physical Address,City,and Tap
ft. ft.
AWG RAWPL-L-c Y1.RElt7tKRffi
County a Parcel Identification No.(PIN) �?•4 y"
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
31.a0-"?W0 N _ 3f- - hI5LIS w &A'AIAAA iS
6.Is(are)the well(s) ermanent or Temporary Signature of Certifirell Contractor Date
By signing this farm,I here;)ceMfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: dYes or ON. with ISA NCAC 02C.0I00 or I5ANCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair,frlt out brown well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back,ofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPP 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t� f� SUBMITTAL1NSTRUCTIONS
9.Total weR depth below land surface: o.0 V (1L) 24a,For„AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ezmnple-3©200'and 2@100) construction to the following:
10.Static water level below top of casing: 2 (ft-) Division of Water Resources,Information Processing Unit,
Ifrwter level is above casing,use"+"' 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: to (in) 24b.For Infection Wells: In'addition to sending the form to the address in 24a
O�.� above,also submit one copy of this form within 30 days of completion of well
ne 12.Well co mcdon method: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(�
13a.Yield(gpm) Method of test: P11 M f 24c.For Water Surly&Infection 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:RT_ Amount: -7 Q2 completion of well construction;to the county health department of the county
where constructed.
FormGW-t North Carolina Department of Fanrironmental Quality-Division of Water Resolurces Revised 2-22 2016