GW1--06739_Well Construction - GW1_20231024

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WELL'CONSTRUCTION RE e- - •CO' .(GW=11 For Internal Use only:
f
. • _1.Well Contractor-Information:
je-40-,r/fi 14.WATER ZONES I .?
-Wen Contractor Name . PROM . TO DD3CD•I1ON .
• ,7 5'3�—4. ova' .
� ri
. far
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NC Well Centimeter Certifieption Number ._
IS ouraft CASING(for mnt eased wells OR LR R(f[ap U bIs)
FROM • TO DIAAIETZR Tffi
C7 a).. .-• a`4' -" ''s ' . R •ft , ' CRtO7S3 MAisR[AI.
• 2.Well Construction Permit 0:r R W L eL v.a3 6�t/ 7 61' PR.INNER CASING OR TUBING(TbeNual H CIO Z op) _ •
PROM TO DIAMETER THICIO�RSS MATERIAL
List all applicable well eonnnrcton perinits(l a UIG Coup%Slat,Variance,eta) -f/ 6/�R i 14, Yo f in' tar /V• I t a
. 3.Well Use(cheek well use): it -
• ' Water Supply Well: • al.SCREEN .
. OA cultural PROM TO DIAMETER SLOT SIZE TSIC[WaSS MATERIAL '
• 'OMtmicipal/Public it • ft I — in. .
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OGeotilermal(Iietitirtg/CoolingSsspply) pt�sidential Water Supply(single) -
• ic is in;
Olnduslrial/Commercial • OResidential'Water Supply(shared)
Ia.GROUT
°Irrigation• OWells>100,000 GPD FROM TO• MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well: •-•- _ L.-. - - - .. . .. . .• _ •- - -- - - D •it w/4 AA.* ;IA j'X e
ct°Monitoring O
• •. Injection Well: Recovery 1�U' ritj l ed.
- • °Aquifer Recharge DGroundviaterRemediationft. ft. I'
°Aquifer Storage and Recovery OS Barrier 19.SAND/GRAVLLPACT{Cdapplinble).
• FROM TO IMATERULL ZMPLACEMINTMETHOD
OAquiferTest ' . . , '. OStormwater Drainage ' R ' tt I: . •
°Experimental Technology , °Subsidence Control ft.. f. j
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• • °Geothermal(Closed Loop) ' - OTracer • 20.DRILLING TAG(attach additional sheets if necessary)
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❑Geothermal(Iieating/CoolingRetum) OOther(explaintmderl121 Remarks) FROM TO • •-'DESCRIPTION(:der,loudness,soWnektrpe,eraiasia.etel
2L ft.
- -. 4.Datewell(s)Completed: /6--/DJ3 well ID# G/GQoa , ft. •ti:
Sec.Well Location: v ::� r
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ft. • R
• FaclIity/OwnerName.. ' , FacilityID8(if applicable) ' , ft. QCT Z
' - ' N14:.'Hr Lc&�. Rdad lTiul' end #lC c) '6".P3 • ft
..i,Physical Address,City,end Zip ' • ' . I r to ft �. •-� ' ,a
5/Jlrnrl� / !e Do.3Z-r�o99 2LREIVIARILSi
Conn1y • Pavel ldentifieatianNo.(PIN) . '
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees: • I I
(ifvrell Sell,one let/lona is sufficient) •22.Certification:
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fit'f ra 134� SiJj#'
Ce&WeII Contractor /e _/ O -G3
6.Is(are)the well(s): rmanent or, °Temporary _- _ -_ _ Date •
JlyrIgningthhisform,I hereby witt rthat the well(i)war drere)constructed Inaccordeneewith
7.Is this a repair to an existing well: °Yes or ' 1 JSANC{C 02C:0100 or IS11 MAC 02C.0200 Well Construcetoni Standards and that a copy
• "Aft isarepalr fill outktown well eonmvctlon information and esplaln the nature of the t ofthis record has been provided to the well owner
'repair under 021 remarks section or on the back of isfone.• `
• • 23.Site"diagram or additional well details: .
-. ' 8.'For Geoprobe/DPT or Closed-Loop Geothermal Wells baying the same . You may use the back of this page to provide additional well construction info
' construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled: 24.SUBMITTAL INSTRUCTIONS
.. • 9.Total well depth below land surface: /.) •
• - For multiple wells lin all depths ifdifferenl(trample-3(a)200'and2(o)J00) (D) Submit this GW l irithin 30 days of well completion per the following:
10.Static water level below top of casing: 8. 24a.•For MI Wells: Original form to Division of Water Resources (DWR),
.lfwater level Is above easineure"+' ` •, (,) ration Processing Unit,1617 MSC,Raleigh,NC 27699-1617- •
•• i
IL Borehole diameter. 6 (m•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
1L- /�, • Program,.1636MSC,Raleigh,NC27699-1636
12.Well construction method: ' • r"oT ri1• ( I r' . ' i _
OA.auger,rotary,able,direct push,eta) 24a For WaterSupply and Open-Loop Geothermal Return wells:Copy to ttte( .'
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county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells pro-clueing over 100,000 GPD:Copy to DWR,CCPCUA
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. • • 13a.Yield(gpm) . S • Method of test: CI r Permit Program, MSC,Raleigh,NC 27699-1611
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13b.Disinfection type ' H 714- •, Amount: • b Z .
_Fnrm OW 1. : North Camliea Department ofIhvimnmmtal Quality-Division of WaterRaourees Revised 6-6-201a