GW1--06943_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
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-3 U () 7Ii ,4 di fi 4i'�/7 rig- 14.WATER ZONES I
Well Contractor Name ( FROM TO DESCRIPTION
ft:;1/-1- Ai- it ss3 ft S� Qpr,7
NC Well Contractor Certification Number •.lS.OUTER CASING(for multi-easegivells)OR LINER(if an Heath)
J e( .4 // )3 f0S f �n C` FROM TO DIAMETER THICKNESS 1 MATERIAL
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J '71 ft. z ft. c ,in. 77.� ✓..!/Jt„4/Company Name 16.INNER CASING OR TUBING(geothermal elosed400p) •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',County,State,Variance,etc.) ft ft. ;in.
3.Well Use(check well use): ft. ft. ;in. .
Water Supply Well: 17.SCREEN • .
.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural givri icipal/Public 0 ft. ft. in.
*Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
*!Industrial/Commercial ['Residential Water Supply(shared) 18.GROUT .
Irrigation FROM 'TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft G kg- ft ;prev)71- .7r;,n:•c).,,, jnstit,
*Monitoring Recovery ft. ft.
Injection Well: 1t it �� 7
d
*Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL PACK(if appueable) •' '
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*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
a Aquifer Test DStormwater Drainage ft. ft.
*Experimental Technology 0 Subsidence Control ft. ft.
111.Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional aheeta'if necessary)•. • . . '
FROM TO DESCRIPTION(color,hardness;soil/rack type,grain sire,etc.)
a Geothermal(Heating/Cooling Return) rjOther(explain under#21
Remarks) Oft. ,f ft. 4e a Y
4.Date Well(s)Completed:9 `7 7--21, Well ID# C C. )14- ft 3f R' 7,1¢n S,-41 f ,t/3to,eijI se•
5a�}Well Location:
/ y / ( * ft s3 ft. ji1As0:0 _Xpn--4-4a "5e,�44�.i/2.
.Z.,ra he, •ti p't;Ty..?evu Les . 'ft. }$- R. C1 /I c" e-t- k s r ;` '.,
P el •• vim- -.,ss..r r kr 7...,"_,,...
Facility/a wner Name Facility 1Db(if applicable) ft. e V .ft. /A
ft ft.
rov-, I/4..ev-i id, 1cufasl,.a. 461 OCT 2 7 2023
Physical Address,City,and Zip tt ft.
7.4€ • e-i l l2r1.REMARKS) i i f'i; ; =:,.e• : �;.- �.r:j 1 :._i
CountyParcel Identification No.(PIN) C f$r'A,,4 f9 fr 4(;✓�..5h ' 1 ILL /�
l/�d' S�z I:c�e.�dY.cLl�.fl b�//�iG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t2 d2Mc7 _t' 4'61 6.. P ,' ° �"a o f
(if well field,one lat/long is sufficient) 22.Certification: , o
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tr / N � `r`$ t/ '/ W t/ SS/ i , r, 7`Z
6.Is(are)the well(s)fa•Permanent or Temporary Si r of Certifi d Well Contractor Dale
By signing this form,1 hereby cargo,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )2lvo with 1SANCAC 02C.0100 or 1SA 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 ofthis record has,been provided to the well owner.
repair under k2l 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 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: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: e: 0 e> (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 tr 00'and 2®100) construction to the following
10.Static water level below top of casing: CJ
a-C (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: 4 (in.) 24b.For Infection Wells: In addition'to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Co7176r construction to the following:
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(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) /2 is t Method of test:A d l•;7 24c.For Water Supply.&Injection Wells: In addition to sending the form to
the address(es) above, also submit orie 'copy of this form within 30 days of
136.Disinfection type:/14r;44- Amount: Z<
completion of well construction to they county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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