GW1-2022-09613_Well Construction - GW1_20221021

_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
17
� FROM TO DESCRIPTION
Well Contractor Name ft. ft.
e15`15--4 ft. rt'
NC Well Contractor Certification Number I
J 60.
' '•PROM TO DIA
MMETER THICKNESS MATERIAL '
l,�i wl�s Y" "'•, ek V a i/lt 1`1 6 O• ft. ft. 12JG In. s 2 1
Com— panyme ' -
/� 1`a ^-CAIi °e d ': N
2.Well Construction Permit#:S W� ~v 5 7 PROM ft, TO ft. DIAMETER In. THICKNESS T MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
rt. ft. la.
3.Well Use(check well use): - . •�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) rL ft. In,
Industrial/Commercial 13Residential Water Supply(shared) �.ttgF;: Ot ,;s :.{ ( ;3;r 3c =8 s: ••'Ft a T 1 °
hTi 8ti0R ft. Q
PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O n• I CL.- 1 . S
•Mcnitoring ORecovery tt. ft.
Infection Well: tt. tt.
Aquifer Recharge Groundwater Remediation ;... \tire
xy_ ./. �...>ti .
Aquifer Storage and Recovery Salinity Barrier FROM TO ` MATERIAL EMPLACEMENT METHOD
Stormwater Drainage
Aquifer Test , � �
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) � Tracer x.
FROM TO I DESCRIPTION color,hardneu solVrack rain sl etc.
Geothermal(HeatinglCooling Return ;Other(explain under#21 Remarks O ft. rt,
4.Date Wells)Completed: r1�1 '� Well ID# tt• ejS
ft. ft.
5s.Well Location: z.. s-
n
140tVll,06 K—1'b yve,11 6 c, rt. rt.
Facility/Owner Name Facility ID#(if applicable)
AA -.,..L._. ; V 6 4-a. 2.6 L:h n r-ov e frat i ft. n. Una
ft. ft. IntLr��a.+�
Physical Address,City,and Zip s ;.
!�
gal::
�l/1cPC,Wet�
County Parcel Identificstion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
'e3G 305 N —81199oo 5
Signature of Certified Wall Contractor Data
6.Is(are)the well(sPermanent or Temporary
By slgn/ng this form,I hereby cert(ly that the well(s)was(were)constructed in accordance
[ Yes or [}No with ISA NCAC 02C.0100 or 15A NCAC 01C.0100 well Comiruction Standards and that a
7.Its this a repair to,an existing well:ction frllbrmallon and explain the natut'e ojthe copy ojthis record has bean provided to the well owner.
(f this is a repair,fill out known hell constru
repair under#21 remarks section or at the back ojthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed�L'oop Geothermal Wells having the same You may use the back this page provide additional well site details or well
construction details. Youu may also attach additional pages if necessary.
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 G ri (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{f d(Berent(grample-3Q200'and 2@100) construction to the following
10.Static water level below top of casing: so (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diat;eter: ro
(in.)
24b.For Injection Weill: Inladdition to sending the form to the address in 24a
r 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.) V
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
13a.Yield(gpm) �t r the address(es) above, also submit one copy of this form within 30 days of
�.' Ov r bL2. Amount: 2t�v S completion of well construction to the county health department of the county
13b.Disinfection type: _ where constructed. -"
Form OW 1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22-2016