GW1-2022-10277_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATEXZONES-:: '
t-I I�Q• /f/�G//I S/ V�'Ff f ey f��7 P✓ FROM TO DESCRIPTION
Well Contractor Name ��vT�13'p n ft. ft. /o (g� JC' /�
ft. rr
NC Well Contractor Certification Number 15.OUTER CASING for multi-coxed wells OR LINER ff a 'l cable
FROM TO DIA,4IETER THICKNESS MATERIAL
22 of Dr,(6'✓1 `/2fr & V in, r.)-5 !JC
Company Name a6.INNER'CASING OR TUBING' eoffiermal closed=loo
/ / 9 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i/�D f �(O / ! ft. tr. in.
List all applicable well constntctim permits(i.e.Cou»ty,State.Variance,etc.) rt. ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic fr ft. in.
❑Geothermal eatin Coolin Supply) estdenrial Water Supply tr ft. in.
(H g/ g pp y) � � pp y(single)
01ndustrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. ft.
Non-Water Supply Well: tr e t 40 u red
ft.
❑Monitoring ❑Recovery
Injection Well: ft fr
❑Aquifer Recharge ❑Groundwater Remediation 19c SAND/GRAVECPACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage fr, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG attach additional sheets ifmcessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn( ess,sotUcvck type.grain s{ze etc.)
❑Geothermal eating/Cooling Return)) )❑Other(explain under#21 Remarks) (!) ft' 2 C) rt,
l /�r © rr 0 ir.
1.!
4.Date Well(s)Completed: i
g p rr rr .5 Sfo n e Z17L-lc �r
5.Well Location:t ft.Moo �Qr O •
P G
r ft. ft.
Faci" /Owner Name Facility ID#(if applicable) fr ft
P
S(o �Ct!v &at /-/1/ it tr.
Physical Address,City,and Zip 21.REMARKS
NOV 2622
County J Parcel Identification No.(PIN) lnfbrma3 an Pr-��M I 1
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `
(ifwell field,one lat/long is sufficient) 22. e 'Ic lion:
.35.9 3G (7.3� N goy R3 '1o� W
� Si a ofCpftrin,
fied W 11 Contractor Date
6.Is(are)the well(s): 21%rmanent or ❑Temporary By signing rhi I hereby certift that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O1V0 copy of this record has been provided to the well owner:
Ifthis is a repair,fill otit known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use fife back of this page to provide additional well site details or well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple b1 ection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#dferent(example-3 00'and 2®100D construction to the following:
10.Static water level below top of casing: ; S (ft.) Division of Water Quality,Information Processing Unit,
#ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:. (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a-
nn 11 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: l l O( _a r t/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality;Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test ( 24c.For Water Suynly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
73b.Disinfection type: Amount: 342inf where constructed.
Form OW-1 North Cnmlina Denartment of F.nvimnment and Namral Resources-Division of Water Oualitv Revised Jan 2013