GW1-2022-09919_Well Construction - GW1_20221031

WELL CONSTRUCTION RECO . GW-1 For Internal Use Only:
1.Well Coutractor•Information:
i
e�Cknd'e C FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Al"'.
V ft.' ft
ft. &
NC Well Contractor Certification Number TA/�+ is.OUTER CASING for multi-cased wells OR LINER rf a Gcable
11Neomain 2 rra&he r s EOM TO DIAMETER THICK
NESS MATERIAL
ft ft. im
Company Name �f•/�//'� {,(/ 16.INNER CASING OR TUBING eothermal closed-lRon
2.Well Construction Permit#: / / I �O FROM TO DIAMETERV4 in. THICKNESS MATERLIL
List all applicable well construction permits(Le.WC,County,Slate,YOHanc elc.) ft. It.
1 GK
VG
ft. ft. in.
3.Well Use(check well use):
7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fc is
❑Industrial/Commercial ❑Residential•Water Supply(shared) 18.GROUT
01rrigation ❑Wells>100000GPD FROM TO I MATERIAL E MPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: h
ft. Z7, R JJ
❑Monitoring ❑Recovery fL it.
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK ifa licabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDminage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIIVG LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hnrdness soiUroek in s' etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:110 "J/ Well ID# 3 O ft. its
ft. ft. A V
5a.Well Location:
ew UM&11ft.ft. r
{�
Facility/Owner Name Facility ID#(if applicable)
ft.5a .�f IREMAI
ga Hwo 7r�/ IRhii 6L�. AlPhysical Address,City,and Zip Z u(�pt� fL2
a1 lea h�j
County J, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) pp / 22.Certification:
,34,.0.7 0 t SE11 N O l y [O t' W ZZ
6.Is(are).the well(s): permauent' or ❑Temporary Sigoature bf Ceitified'•Well Contractor Date
By signing this form,I hereby cerl fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 15A NCAC 02C:0100 or'15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided io the well owner.
repair under 021 remarks section or on the back of thisfom. 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach.additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer f 4
For multiple wells list all depths!fd fferent(example-3@200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
` 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: d VO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �O {in.) Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: r 0-bon., (-A; r 24c.For Water Su 1 and O'en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmentdl h th department of the county where installed
FOR WAT>;R SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 $s r
13a.Yield(gpm) .S� Method of test: A If t
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-20.18