GW1--06866_Well Construction - GW1_20231030

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, 'vP LL CONSTRUCTION RECORD(GW-11 For Internal Use Only: i , :.
1.Well Contractor Information:
Jerri Wc1,4-kr1,
Ieli Elf:WA • NFs.= : -_: "___...- :,____I '•-t
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Well Contractor Name /FROM O DESCRIPTION
• ft. OStft 'li GPM�!
Si5� A ft. 190 ft. 3 OP en . -coi-
NC Well Contractor Certification Number ---- -
'.CASING(foi multi=cesed;�VeILi):ORI�VFR-(if'ap licslile)_-_.-_ ._ ''NYadkin Well Company, Inc. FROM To DIAMETER THICKNESS MATERIAL
f t ft. 20 ft. ,q if in. --cfe t K
Company Name r --^" � �1 (�
,.- 16.INNER?CAS NG OR'TITBING:aititlidiiiiitd'o'sed trots :_:__-.__-.__:_.:-
2.Well Construction Permit#:k � ��� -'' FROM TO DIAMETER TBICERESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Yd hest e,-etc) ft. ft, in. Ci
3.Well Use(check well use): ft. ft - in.
Water Supply Well: . „ - --- -- - -- - - -- - -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mnnicipa]/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial )(Residential Water Supply(shared) 18 GROUT' _ _ - _
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: ft, ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
DAquifer Recharge ,❑Groundwater Remediation
_19.SAND/GRAVEL PACK(if•applicalile):. _ - - - _ _.
❑Agtufer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology OSubsidence Control ft. ft. •
OGeothermal(Closed Loop) ❑Tracer 20 10.11 NGLOG';(attar-h`aadihonsls3eets:iEneceisary1:____ _____ -_.
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks)
Date Well Started /612 123 SD
C,e // too' 14cd`' C n r7
4.Date Well(s)Completed:1016173 Well ID#PPR 4 V ft ft.
Phone#:$13- 14 7- /37C ft. ft
�5a`.Well Location: [� + •erj,bc( (e •� ^- T-.
�.Qru 1 i.rte. �LT�"f/Sell)e o- rN ee v ft ft , -/.. r-•
.z , r•
• 6� 0. .+£._ cc n
Facility/Owner Name y�f Facility ID#t(if applicable) ft ft. OCT
y
/Oakley LP% lSInGJf✓!!.r faC>C lit ft ft UI I aD IY 2023
Physical Address,City,and Zip J it. ft. In;,,,,,,,_ ..;1 :3..-_ _ I!r-:
`` ' 21:403M&RICE: LIC;_=.,;. `a ___
KJ'(.C(6((�.9 GI -
County Parcel Identification No.(PIN) '7 90' boo ha k)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificatio
3(, 0 1(ca 1( fr.. N 5°1. Co 23 I , /46193
6.Is(are)the well(s): igermanent or OTemporary S tut-of C ed Well Contractor Date
By signing this form, ereby-eer6fythat t e wells)was(were)constructed in accordawith
7.Is this a repair to an existing well: ❑Yes or $14o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 e n -lton n arils and that a copy
If this 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 G7-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. r g
drilled: 24.SUBMITTAL INSTRUCTIONS `�
9.Total well depth,below land surface: 14100
(ft.) Submit this GW 1 within 30 days of well completion per the followings
For multiple wells list all depths ifdifferent(example-3Q200'and 2@l00� si.
10.Static water level below top of casing: too ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bit Off: .S 900 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 f " 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,directpush,a county environmental health department of the county where installed G
'\
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 2
A Permit Program,1611 MSC,Raleigh,NC 27699-1611 R
13a.Yield(gpm) Method oftest: /�I t v„
oDate Site Visited:/N 2.,i.
13b.Disinfection type: 70�o hth Amount: 3( OZ Site Visited By: 0 p
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Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018