_Well Construction - GW1_20230315 (7)

r 1 1!I C-1 V I III
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
COOL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� ft. O
�j5 7 7� t a5 ft. 130 et. 1 GGTP/'`1
NC Well Contractor Certification Number IS.OUTER'CASiNG for[nutd cased'wens OR LINER ire Ucable
FROM TO DIAMETER THICKNESS I MATERIAL
Q ft. 5 ft. in. 5 1) 1" vL
Company Name 16.INNER CASING OR TUBING(eothermnl closed-loop)
2.Well Construction Permit#: W Q `h 3$d FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Q t't. W ft. 'n 0 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
r Agricultural OMunicipal/Public G ft. ft. in.
Geothermal(Heating/Cooling Supply) C- esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
I�
Non-Water Supply Well: d it. ft. o a �,
Monitoring lORecovery ft. ft. 7 S—v NS
Injection Well:
Aquifer Recharge Groundwater Remediation D. �v f t. (i � SU 1 b 5
19.SAND/GRAVEL PACK if applicable)
f Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test l3Stomlwater Drainage ft. ft.
i Experimental Technology OSubsidcnce Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary)
i Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM TO DESCRHrrION(color,hardness,soilf ock type,grain size etc.
U ft. ( It. 1 1
4.Date Well(s)Completed:(-oZ0_a 3 'Well ID# ft. o tt. Gre l
Sa.Well Location:
CAC&A co Non e.S
Facility/Owner Name Facility ID#(if applicable) ft. ft. F t A n
Ej �1 t ft. ft. ni� i L 'LJ
Physical Address,City,and Zip R 702 7 Vft. ft.
i
21.REMARKS f
orp QQ } 6rPM •n C.AS 7 n e
County t Parcel Identification No.(PIN)
Sb.Latitade and longitude in degir./minntes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1055'%q7 N �79. Ial3S2.5 W 12� LIE 7-? G t-ao-.23
6.Is(are)the well(s) —ent or OTemporaty Signature of Cemfied Well Contractor Date
By signing this form,I hereby certify+that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 0No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell 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 farm.
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: t, SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: Q—IC) (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 200'and 2@100) construction to the following:
10.Static water level below top of casing: CQ S (ft.) Dlvfsion of Water Resources,Information Processing Unit,
if water level is above casing.use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: �o (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: i r I-e)"42.ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) oc Method of test:RJOWt1 oZ0 In.'A 24c-For Water Supply&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: N eH Amount: it o Z completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016