GW1--03757_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM ft. TO DESCRIPTION L
yp ft.
A ft..
ft.
NC Well Contractor Certification Mimber t15 OLCI7ER C'11SING!Co` mOXfi=c652davells c'�R liI1�lE1T if a"`11cabIE ' y^ s�a folAt
L p FROM TO DIAMETER THICKNESS MATERIAL
ft '� 9 ft' in. e ! `b �!
Company Name V 16;S1NNER;CASINCiOR�TIH(Fotheruiclofredtlao
2.Well Construction Perm p�it# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Couno;State,Variance,etc.) A R In.
3.Well Use(check well use): ft, ft. in.
CSC I771!17»>= ._.aR a,;a.)r:•r..`;
Water Supply Well: FROM TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑ unicrpal/Public ft. ft. in.-
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) z18t RU[.--T
❑Irri ation ❑Wells>100,000 GPD FROM TO MATETAT -- EMPLACEMENTMETHOD&AIMOUNT
Non-Water Supply Well: o it. �� it. �`
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
419';StANA/G IZIN,11 erlf It`a"f call e t `
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer OE]Jtr 1iRITT1IN.G t U atricli'addfEiouaTs�t ets icnecess"" i. .;c. ::s r,.,s. :
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardne solVrack tour,site eta)
0 • J rt. C. y f S'Q V1Cl.
4.Date Well(s)Completed: A d d•+J Well ID# I so rt. • - .10.ft-] J , f4_ ro G K
Facility/Owner Name Facility ID#(if applicable) ft. fL 2
r N"©u aG fc. rc. Ur.
ft. ft. 1rtyG:T•y.:. a
P}ty�et`;'cail Adclnc,;,('.ity anrl7..i-
..�C.l jN
County Parcel Identification No.(P12,1)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 1
(ifwell field,one lat/long is sufficient) 22.Certification: 1
Signature of Ceitified Well Contractor Date
By signing this form,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V o ISA NCAC 02C,0100 or 1SA NCAC 02C,0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner,
repair under#21 remarks section or on the back of this form.
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 surface:... -- t�0 (ft.) ,::�::_„.�,r.,••,,,•,_�.,:e::,R :.� _'••" -._.._ r:�•:-:::r:.-.
.. .. . .. . .. ........ ---- - -.. _ .. ---- -- - - - - -- - - -
10.Static water level below top of casing: �® (ft,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f watt•level is above casing,use op
11.Borehole diameter: �/ (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
�J Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Q(f' char/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
-FnP WATRP CTTPPT V WR-T A ONT,V. - -
�__ ___ __-
13a.Yield m Method of test: b l o� Permit Program,1611 MSC,Raleigh,_NC 27699-1611
(l;P )
13b.Disinfection type: Amount: a 5 16 5-
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018