GW1-2022-09363_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Weal Contractor information:
Y4.WATER ZONES
Well C�onra FROM To DESCRIPTION
CctorName i 1 pl R.
( /t
1, `) 7 W ft.
NC Well Cofactor Certification Number
c. `']s':Or/I'Fdt'GASn TO DIAM
1TG' �3rorn �eacAr' "trir`IIPPEK` ._ffwDle
OM BTSR CIUVB33 TBRtAL
Company Name 16.INNER CASING OR TUBING; dosed400
2.Well Construction Permit A: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Coroety,State.Variance.etcj ft• ft. in.
3.Well Use(check well use): ft' fL
Water Supply Well: IFMM 7SCitEBNro DiAhiETRR :LOT size THICKM+SS ' MATERIAL
Agricultural ipallPublic 0 tt. rt.
Geothermal(Heating/Cooling Supply) widential Water Supply(single) % IL in,
Industrial/Commercial E)Residential Water Supply(shared) Yg GROUT
_:Irri ation - FROM TO MATRRI OI) AN
Non-Water Supply Well: ft- ft. 0
Monitoring � Recovery
Injection Well:
Aquifer'Recharge' DGroundwaterRemediation
Aquifer Storage and Recovery Salinity Barrier FROMAND/GRTo PACK MATS a PLACEMENT METHOD
Aquifer Test E)Stottnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. FL
Geothermal(Closed Loop) Tracer 20.1)RII,LINGI.UG atmcb'addldonalsheets if
_. bw
Geothermal(Hearin Coolm Return _ Other lain under#21 Remarks FROM To DESCRIPTION t�icrveadr r�
p ft. ft.
4.Date Well(s)Completed: `�a ~ Well ID# ft. ft.
ft, ft. <,
S,aa. ell Location:
ft. tt.
r i �( ft. ft.
Faoi(litty/Owner Name Fac:7ity M9(if applicable)
ft. Jtz>"v
Physical Address,City,and Zip 7 ft.
P�;rsaeL 21.REMARKS
�
County Parcel Identification No.(PIN) t c m
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: rp
(if wall field.oneella�tnongg is sufficient 22.Certification:
SCO1 `1ft_=r�" fO.N 79 _o 1As` VLP0 W
6.Is(are)the welts) _Permanent or OTemporary SigMure of Certified Well Contractor Date
By signing this forme,I hereby cerq)�that weills)was(were)constructed in accordance
7.Is this a repair to an existing well: 64". or EINo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out 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 of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled I (� SUBMITTAL INSTRIICTIO 1
9.Total well depth below land surface: ` -l A) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1®100) construction to the following:
10.Statte water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"t r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._ l� f' (in) 24b.For Infection Wens: 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- construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
h
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mati Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ` Method of test: 24c.For Water Sam&At Iniection 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: Amount" G i nc-,e_S completion of well construction`to the county health department of the county
where conshucted. .
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Reso i Revised 2-22 2016