GW1--03943_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1. ell Contractor Information:
NES
FROM TO DESCRIPTION
Woll Contractor Namtt ft'
NC Wed Contractor Cc ' cation Number 1S;•U R.0' for.. *cased wells OR INER'it's cable
TO IAMETER TMCtOMS MATEItrAI
FROM Z
Company Name I6.' CASING ' edt.ermel'•ti Died-too
FROM TO DIAMETER Tfficlam
MATERIAL
2.Well Construction Permit#: ft, ft. U'
List all applicable well construction permits(l,a.EX,County,State,Parlance,etc.) ft. ft.
3.Well Use(check well use): V.SDREEN
Fj, ;;]0ReSIdc
upply Well: FROM TO DIAMETER SLOT SIZE THrC10QESS MATERIAL
MunlcipaUPablic ft. ft.
ltural •�rmal(Iieatillg/Cocling Supply) �ltgsidential Water Supply(single) ft,iaUCommercial Residential Water Supply(shared) 18.t; .yq EMPLACE T METHOD&AMOUNT
FR°M TO oon �(� Gter Supply Well: ft.ring ' RecoveryD ell: tt.r Recharge Groundwater Remediathon 19,SANO/G ''VEL FA IE it a II a leM LACEMENT METHODer Storage and Recovery Salinity Be,cter FROM To MATERUL
to ft.
Aquifer Test 0Stormwater Drainage
Experimental Technology ^•.�f [)Subsidence Control
L1N OG. trea
Geothermal(Closed Loop) �Tmcer 20.'IY t!' ii 1HOaalsheet:if aecesse� a�era
FROM TO DESCRIPTION color hardaeaa aoWroek
Geothermal Heatin Coolie Retttm Other ex lain under#21 Remarks ft. z fr.
n-' We11 ID# fL IL
4.Date Well(s)Completed. 31- ft. ft.
So,Well Location: ft. ft.
Jo;�►t ryl t°/�S l,o/15 ► o� cr, fr, I�l n _
Facility/Owner Name Facility ID#(if eppd cable)
I W f
Coo i�l etik ►'cla,� ft' �;, n
ft, fi. liltvt'i7' jy
P sicol Address,Cr and Zip 21. ARKS
L—
County parcel Identification No.(PW)
5b.Latitude and longitude In degrees/minutes/secont.9 or decimal degrees, 22.Certifleationt
(irwed field,one latliong Is sufficient) '
36, 52 3('t 2 w
" Si ttiroofCertitied Wdl Gntraetor Date
6.Is(are)the well(s)oermanenl or oTemporary signing this form /hereby WHO that the well(a)tvos(rusts)constructed In accordance
By 7.1s this&repelr'to an existing well: —Yesor.�No _-- ___ with ISA NCAC 02C.DI00 or ISA NCAC 02C.0200 Well Consowctlon Standards and Thar a
copy ojihis record-has boon provided toAe-well-owner,
Low is a repair,Jiil out(mown well construction information and explain the nature ojthe 23.Site diagram or additional well details: .
-repair under#21 remarks section or on the back of this form,
vide additional well site details or well
You may use the back of this page to pro
S.For Geoprobe/DPT or Closed-Loop;Geothcrmal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells eTrua•* A r iN4 TRUCTION$
drilled: — /�/
9.Total well depth below land surface: 10r b (fG) 24s; For All Wells: Submit thus form within 30 days of completion of well
For multiple wells list all depths(fdtTerent(e)arpple-3 aL1200"and 2@1001 construction to the following:
10.Static water level below top of casing; (N-) Division of Water Resources,Information Processing Unit,
If water level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
g the form to the address in 24a
11.borehole diameter: 24b.For Inlection Wells: in addition to sendin
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground 1nJection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test:��� 24c.For��r SU h&Infection Walla: In addition to sending the form to
13a,Yield(gpm) the adilress(es) above, also submit one copy of this form within 30 days of
i r►11�. Amount: ' completion of well constrticthon to the county health department of the county
13b.Disinfection type: 1�( where conshucted.
Revised 2-22-2016
North Carolina Department Of Environments!Quality-Divisloo of Water Resources
Form OW-1