GW1--05581_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD(GW-1).� For Internal Use Only:
1.Well Contractor Information: ciAp E / -- '^
41 !Ai.2e �
FROM TO DESCRIPTION
Well Conh'aclor Name
?.3-A- 4‘ 2. / looft. (v3 f � 7 r1/y,A 1" 4 TIt/?
4 2
A
NC Well Contractor Certification Number i'YS OUIRERCASING(foNmul'tircese8 ivenWORi INER(IfmpLLlrliettil'e)
QejvF A, c 7
,,,4 ///� FROND DIAMETER in. THICKNESS I MATERIAL
2.W Company Name �i R3 7 3
2 r 22.111 'lfiA, HER-G'ASINGIORMUBING4Ueitthermal.elosedabnp),
2,Well Construction Permit#: FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) �"/0 ft. gr C ft 4';sr in, `' f/o / S C.
PB•/'Al , 412i 1 9 ft, ft, T in, T'r
3.Well Use(check well use):
17,:SGRBI N',
Water Supply Well; FROM TO ,� DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public . .p
Geothermal(Heating/Cooling Supply) Residential Water Supply(single rt, ft, in.
Indgatiial/Commercial ed) le tGAOUsr ft !� !
Irrigation FROM//'' TO MATERIAL7� EII7PLACE�ME{N�TMETNOD AMOUNT�,,/�
Non-Water Supply Well: L/ !.)1t��77 //tt uY •
_- ilMonitoring - _ - 0Recovery - - -. ,ft, ft.. - - - -
Injection Well: • ft ft.
Aquifer Recharge 0Groundwater Remediation si1 -
9:SA'ND/GRAVEI:PACKI(Ifappticable) •
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft. .
Geothermal(Closed Loop) OTracer +2eMtRILLLINWEOG(attuieliiad litidnelislicdteaf receesery) . ••
FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Et Other(explain underj,/ #21 Remarks) d ft / J I - sV,(„ i SRC ,0��,�
4.Date Well(s)Completed; )�1l ID# 712/f /L?ft' TI/ft. 18 glOGa�/A/ /1/x L"'7,Giektie
. Veil Location: /Y
Facility/OwnerNafne vV^` f�.FacilityID11(ifapplicable) ft. ft. c/C
5-' / „P"�,_(p , ,�" .�!� / ft. ft. E T •• m,
�r'r Zip �- /V ft, ft. it..V ii V ?I
Physics A dress,City,and
fti: Cr
oDve • f lD 06024/o3 u.A mmRlc AUG Gi 0 20LJ
County Parcel Identification No.(PIN) •
' interAIDUCTI P fC14.0411g lin
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ( S1---'i
(if well field,one lat/long is sufficient) 22.Certification:
3s.14a'.s- (. N 79 .S38/ 7 7w '�4*-ss.11 is-47,172_3
6.Is(are)the wells) manent or Temporary SignaturrofCertified Well Contractor i Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or fF r - with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
-- 7f tills Is a repah,ill out knowtrwell construction infortiiation and exp/a1rrthe nature.of the....,copy of this record has been provided to the well owner.
repalrunder 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT os d- op Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 G Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /// / /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (O a C (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r@t 200'and 2Q100) • construction to the following:
i
10.Static water level below top of casing: 4..1"
i it i j 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: <l/c// (in.) 246.For Infeetion Wells: In addition to sending the form to the address in 24a
�h f /. above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �I/I� above
to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Lljection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/�
13a.Yield(gpm) Method of test: • un1/4 24c.For Water Supply&Infection Wells: in addition to sending the form to
H.
the address(es) above, also submit one copy of this form within 30 days of'
13b.Disinfection type: ty.7 �7. Amount: /8 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016