GW1--03726_Well Construction - GW1_20230602

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WELL CONSTRU CT ION RECORD(GW-1)
For Internal—Use Only:
1.Weil Contractor Information:
`• �t /� '4•.'.AT R.xQNES FROM TO DESCRIPTION
/�V 1 lh��\I✓
ft.
Well Contractor Nam%
NC WaU �a �lion Number 15r U It•G form DIAMETER' adetla O 17CIER s a cMabAle wnL
��� TONFROM :CASIIIGOR.", edtliarCompany Name j /� / z FROM TO DIAMETER 7�CLINESS MATERIAL
2,Well Construction Permit#:
7J ft. ft. In.
List all applicable well construction permits(l.e.fflC,County,State,Variance,eia) ft. ft. tn'
3.Well Use(check well use): 1.,, r . EN
FROM TO DIAMETER SLAT SIZE ffDC1INESS MATERIAL
Water Supply Well: ft. ft. In
Agricultural �MunicipaUPitblic
ft. ft.
taeoUtelnal(Heating/Cooling Supply) �.sidential Water Supply(single)
ot�IResidential Water Supply(shared) 18,. EMPLACEMENT METHOD&AMOUNT
IndustriaUCammercial FROM TO NATERAAI'
Irri atlon ft. 0 ft.
Non-Water Supply Well: ft ft.
Monitoring Recovery
ft ft.
Injection Well:
.
®
Aquifer Recharge Groundwater Remediatian 1g,3AATA/GRAVEL FA It Ito ll a le• EMPLACEMENT METHOD
Salina Barrier FROM To MATERLAL
Aquifer Storage and Recovery., \ti �' er fL ft.
Aquifer Test ".��\ 0Stormwater Drainage
Experimental Technology ? [)Subsidence Control
tR ft.
20.'1) LiN OG. ttach' 'il pn sheet:if•naeesea• etza eta
poothermal(Closed Loop) �Tracer daes FROM TO DESC TION color har eolUreek
Geothermal HeatinglCoollng Return Other ex lain under#21 Remarks ft. ft. d G L
5` Well ID# c6/�ft. ft. 1
4.Date Well(s)Completed: ft. � ft.
Sa.WellLo adoa ��: I t r ft. ft.
I
1 �. to
I .I'L rC.1 ft.
Facility/OwnerNamo Facility Wit(ifappUcable) 1"qI r 2023
Rd, ft , U IV V
Physics) dress,.C'ty,and Zip 2I.RE ARKS
U. k, I
Parcol identification No.(PIN)
County
Sb.Latitude and longitude in•degrees/minutes/secontts or decimal degrees'. 22.Certification:
(if wail field,one letilong is sufficient) ,
I !Q w ��` *Jn�
Date
signature of Certified WeU Contractor
6.Is(are)the welts) ermaneot or•Temporary• By signing this form,1 hereby certify that!hs weli(s)was(were)constmored in accordance
[�' o with ISA NCAC 02C,0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.<s this a repair to an existing well: EJYes or J�C" copy of this record has been provided to the'veil owner,
7.is Is a repair,fill out known well conse"ot►on Information and explain the nature ojthe
23.Site diagram or additional well details: l well alto details or well
•rdpair under#21 remarks section or on_(hg back of this form.
You may-use the back of this page to provide additiona
8.For Geoprobe/DPT or Closed=lrbop,-Geoth'ormal Wells having the same construction details. You may also attach additional pages if necessary,
construction,only 1 OW-1 is needed.'Indicate TOTAL NUMBER of wells eriBl�I'J AI_INS�R _IL(�fI9
drilled: —
Total well depth below land surface: (ft.) 24a: Far Ail Wells: Submit thus form within 30 days of completion of well
illed:
For multiple wells list all depths(fd(fferent(example-3 00"and!01001
construction to the following:
5 D (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casings 1617 Mail Service Center,Raleigh,NC 27699-1617
Ij'valer level Is.abova casing use"+",
11.Borehole diameter: (/�- _�—(� 24b.For InlecHon Wells; In addition to sending the form to the address in 24a
above,also submit one copy of this forth within 30 days of the of well
12.Well construction method'.
r 0 CL construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
[13a.
WATER SUPPLY WELLS ONLY:
Method of lost: A� r 24c.);fir Water Suy213 Idf Injection Wens: In addition to sending the form to
ield(gpm) the address(cs) above, also subnut one copy of thus form within 30 days of
completion of well construction to the county health department of the county
Disinfection type: L 0 Amount: lC where constructed.
Revised 2.22-2016
North Carolina Departmont OfEuviroamental Quality-Divlsloo of Water Resources
Form OW-1