GW1--07094_Well Construction - GW1_20231103

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WELL CONSTRUCTION RECORD OW_I
.• ' , � For Lltt;rnal Use Only:
1.Well Contractor Information:
l 1ld- ,rnika• r i '
Well Contractor Name 14•WATER ZONES I
�e( FROM TO DESCRIPTION
18_2 IL ft. I
NC Well Contractor Certification Number ft ft,
�J 15.OUTER CASING(for multi-cased wells)OR LINER Of ap llcahle)4 4...rc c',:d e br1 16d",..9��Jj FROM TO DIAMETER THICKNESS MATERIAL
Company Name 9 ft. I R, In. I
2.Well Construction Permit#: e��Qd 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction pe nits(i.e.UIC.CowtiyState,Variance,etc.) FROM TO DIAMETER THICKNESS MATERIAL
R. ft. in.
3.Well Use(check well use): Per-A,rns—1 id 6`•° rr e
It. rt. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricitltttral ❑Mnnicipal/Public
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OGeothermal(Heating/Cooling Supply) , ❑Residential Water Supply if it.
in.
❑IndustrieUCommercial PP Y(single) ft ft la
❑Residential Water Supply(shared)
Oh-ligation ` 18,GROUT
❑Wells>100,000 GPD FROM TO •
Non-Water Supply Well: MATERIAL' ENIPLACEA1ENTntETHOD d AMOUNT
ft. ft.
❑Monitoring ❑Recovery '
Injection Well: ft. ft.
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[]Aquifer Recharge tft3d ndwater Remediation it' ft.
DAquifer Storage and Recovery ❑Salinity farrier 19.SAND/GRAVEL PACK(if applicable) .
❑Aquifer Test FROM To MATERIAL EMPLACEMENT METHOD❑Stotmwater Drainage . . ft. • ft; f
❑Experimental Technology ❑Subsidence Control
• ft. ft.
GGeothelmal(Closed Loop) ❑Tracer • 20.DRILLING LOG attach additional sheets if necessa •OGeothermal(Heating/Cooling Return) Cher(explain under#21 Remarks) FR°31 DESCRIPTION'color!indite toll/rockc •rain size,etc.)
4.Date Wells)Completed:lO"'aS'� Well ID# • S , '_A,gliea, s rep.5C4.'s 9,1 dr /6.7
R' • •it.
��:",a,��'u car¢ Sot rs 42-
5a.Well Location: ft. ft.
oiffer our eletwer ..5-T , ,:.4.•5, e Neh e 216/51994)" ft. ft. • !- • -
','lr;'y ,..�.
Facility/Owner Name •Facility 1b0(ifappficable) it• ft.
2 e2,7 CVeveve l3/g ekse.fl,J•i e) 2 V� ft. ft. , t,
Physical Address,City,and Zip
4f-11/30 i ?8i 8 21.REMARKS
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County Parcel Identification No.(PiN) !74-e r- x-� �
Gt-A, /�' A- /ct i D y✓
Sb.Latitude and longitude in degrees/minutcs/se5 or decimal degrees: ge Ca,ir' i ethch. let;c pohCo,oPSrtreC'No orrGl C➢ftLolS
(if well field,one Iat/long is sufficient)
3111 ���� •f��ry j 22.Certification:
o
N ,. 3,61 it, W ��, 2
6.Is(are)the well(s): t t rmanent 'or OTemporary
ignature ofCcnificd Well Contractor
® Date
7.Is this a repair to an existing wt H: OYes or �f{tp By signing rhisform,Iltereby cep/if r that the well(s)was(' ere,)constructed in accordance with
ISANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
Olds is a repair,fill out known well construction it fotruation and explain the nature of the alibis record has been provided to the well onmer.
repair under 021 remarks section or on the hack of this form, I '
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 GW-1 is needed. Indicate TOTAL NUMBER of wells '(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
‘^ 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (rt•)
For nod!lyle wells nu ail depths i/d�ereut(monde-3Q200'and 2(✓/00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ' / •(ft,) '24n. For All Wells: Origrinal form to Division of Water Resources (DWR),
If water level is above casing,use +% infonnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II.Borehole diameter:' 6 (Ill,) , 24b.For Infection Wells:Copy to DWR, Underground Injection Control(lUC)
f�`' I' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i\® 1 cll..-.1 Oelf 1.4 I '
(i.e.auger,rotary,cable,direct push,etc,) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,INC27699-1611
13a.Yield(gpm) Method of test: !
13h.Disinfection type: Amount: I -
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources na..-+c.r._i n+o