GW1--04809_Well Construction - GW1_20230721

Priit Form `
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ' ' '
1.53ontrat1nrormafion ,, 14.WATER ZONES• . .,
Well Contractor Name FROM TO DESCRIPTION
`/ /p
Oft. ) ft. tp.i.,e�� " // ft. /C/ ft.G � yloJ 44.
NC Welt Contractor Certification Number Q1,vviviioinq 15.OUTER CASING(for multi-eased•wells)OR LINER(if'Sp•llcuble)y 61 \/') /,1 FROM TO qDIIAIMETER THICKNESS MATERIAIY/iv/� y\v� p ft. /// ft. 1. /ptin. 6L‘ L,V Jam,Company Name .
16.INNER CASING ORTUBING(geothermal closed-loop) ...
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,err.) ft. ft. in.
•3.Well Use(cheek well use): ft. ft. in.
water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public /a eft. /y�ft. / in, �a G�j yv (jt:
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Residential Water Supply(shared) i8,GROUT
jdustrial/Commercial
rigation FROM TO MATERLU EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWell: ry Oft. J ft. �p
MonitoringI Recove It. It.
Injection Well:
Aquifer Recharge ( Groundwater Remediation ft tt
_ 19.SAND/GRAVEL PACK(if applicable)-- - .
Aquifer Storage and Recovery Salinity Barrier FROt11 )/-090 b1ATE IAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage /�,[t. tt. .�7"�G'y 'ti/ ,O✓/
Experimental Technology Subsidence Control R. ft. /7 I
!Geothermal(Closed Loop) (Tracer •3U.'DRILLiNC.i3OG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.soil/rock type,grain size.etc.) •
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. A ft.
4.Date Well(s)Completed:1 C V O Well ID# ft. 2ft.
/
":2:://:(4411
5a.Well cation a rt. p ft.[y J/'�°I
ft. (� ft. G She//c e.
t)
Facility/Owner Name Facility ID#(if applicable) //gf't, /j(� ft. ®'f `;:,R,
Ul5 `ftvn J /ft. ft. a COVED
ft. ft. J!�l
Ph sical Address, y:y,an�d/Zii / o (ill-
I/ 9 y 2023
A---
Y - �K�1_-7I.,10( ll- 21.REMARKS. 111.J.prna en,- ppf d U
County Parcel identification No.o.(PIN)/ DWCV 111 $
03
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
✓ N W I i 9/5
6.1s(aie)the well(s) Permanent or DTemporary Sig.azure of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well 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 form. '63
23.Site diagram or additional well details: •
c.
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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)y 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200';and 2 ct 100') construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1/� Vnr�� above, also submit one copy of this form within 30 days of completion of well
M1
12.Well construction method: V 1 + A19/ 0/ V 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) 0 •
1/�1^Meetihod of test: Q v� 24c.For Water Supply&Injection Wells: In addition to sending the form to
type:V"�®*lv 'u(/ �Z� the address(es) above, also submit one copy of this formwithin 30 days
of
13b.Disinfection Amount: completion of well construction to die count health department of the county
where constructed.
• Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016