GW1-2023-02139_Well Construction - GW1_20230303

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ALL CONSTRUCTION RFCORD(OW-1) For Internal Use Only_ -
1.Well Contractor Information:
Pat!71'�� � /t
b �(a:r��j 3.4.WATER$O1�S
WelI ConuactorName kROpbi O II DESCREMON
ft_ 4L C( nCG / (�7
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i'.j NC1VellConbmctorCefificationNumber
�,( l 15.017TLRdAS1IdG fnrmul&ctsed;vells MINIS
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I ' I IY f.�( i�j TRORr O DIAMETER TffiMI'IPSS MTERUL
! j I P Y �p {•I in. (AO
Com an Name rmal rj
16.IL��RC&,SInTt;OItTQEIp1G. eoureclosed-Ioo
i 2.Well Construction Permit#: (8 FROM ir0 DrAbEE M THICKNESS VIATERL4L
List all appEcable nvil constructionpe airs(i e,(IIG CaUnW,Stare,Variance,etc)
I 3.Well Use(chedt-well•use): ft, I ft in
I Water Supply WeIL- i7.S9&EN -
A GtIItLTal FROM TA! DIAMETER SLOT SIZE TSICrCt[ESS MATER
al/l'ublic it ' fL is
f V Geothermal(Reating(Cooling Supply} esidentlai-Water Supply(single) I ft in.
Iudustrial(Commercial OResidential Water Supply(shared)
Irri flan N.lY1LOFIT
FROM tro, I 1vraTrrrrnr EMPLACENEIt'TIYIETHOA&A4f
LVoD-r ater Supply Well: rt 0 IL P C J la O� e
Monitoring Reecovery iL I ft.
trajection Well:
I
3 AguiferRechazge �Groundwaterl2emediation sr.
11SAND/GRikVEL PACK'Ctfa ncable
Aquifer Storage and Recovery El&alinityBarrier FROM TO MATERIAL EMYLACII1tEfyTMETH01;
Aquifer Test .; StomwaterDrainage ff.
Experimental Technology OSubsideuce Control ft I it
;`Geothermal Closed Loo
p)Op) fQlTiaeer 20.331ilLLINGLOG(atfaehaddifioaarshcetsifnecessa )
—)Geothermal(Heating(CoolingRebam) - Other(expiainunder#21 Remarks) I WDN To nESCRiPTiori(cosac.>,arauess soar[n�c ty G"tarn 5rza
a ft Reid ft. e l
,
4,Date Well(s)Completed: 22 WeUEM
S eU Lccation: 2 ft. au-v Mr
ram• 1 '
ft. I ft
FacilitylOwnerName f FacilityID#(ifappllcable) ft I ! ft
Physical Address,City,and tip fl: I it. ,.
CountY�— ParcelIdentriieationTlo.(PIN) MAR
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5b.Latitude and longitude in degrees/mimtes/seconds or decimal degrees:
j
(ifwell field,got:lattlong is"f5cient) 22.Certificat;a ljr;i
6.Is(are)the well(s) — Permanent or E3Temporary SigntmeofiCeriffed.WeUGATractor Date
By signing this Jl orm,I hereby certify that the tvetl(s)war(were)constructed in ace
7.Is this a repair to an wdstingwell: Oyes or o ivitlr 15ANCACI01C.0100 or 1SAIVU-C 02C•0200 Well Construrflon Standards ar,
IJlhis Is a repair fdt out let?wn hell co-ir=iion iitformotiott and explain the Ila[—ofthe wjV ed[lr reco has beenprovided to the well owner.
j repair vnder A21 remarks section or on[fie back afthisform
23.Site diagn in or addifional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use h6 back of this page to provide additional well site details
construction,only 1 OW-1 is needed. Indicate TOTALNMaER ofwells construction d tails.You may also attach additional pages ifnecessary,
drilled: SUBNIMAI INSTRUCTIONS
P 322� ft.
9-Total well depth below land surface: ( ) 24a. For All ells: Submit this fomt within 30 da s of completion
FormultiplewelLslistall depths ifdperent(example-3Q200'artd2Q100) constmctioutc hefoltowing: y p
0.Static water level below top of casing: �a (ft) Di I ion of Water Resources,Information Processing ITDii;
f uvrer level is above casing,use
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Iui ltfon Wells: In addition to sending the form.to the address
t �� above;also submit-one copy of this form within 30 days of completion
.12.Well construction method: r (`
I consttnclioato the following:
i I ! (.e.nuger,rotam cable,direetpusk ere-)
! Divisiono RTaterResources,YTndergroundNectionControlProgr
FOR WATER SUPPLY WELLS ONLY: 636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LS )Method of test: t 24c.For Water Sunniy&Iniection Wells: In addition to sending the:
d the address(es) ibovc,'also submit one copy of this form withifl 30 c
13h.Disinfection type: Amount: J lY completion of well construction to the coup heah
I ! where construe h`health deparnnent o£the
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