GW1--00467_Well Construction - GW1_20240116

1.Well Contractor Informatiin: \ - I
4 // ! / . / / / / /(/ ••14.WATER I_ :, •-` ::.:.;.;
Well Co`ntttactoorri:,,.,,e(30 g FROM TO I DESCRIPT/i�INi `� /� ,
ft. ft.. / - llyy
NC Well ontractorCertiff cation Number ./.
���/1 a J� /J// �,^ i IS:OUTER:CASING(fo'rmnlh-cased'" Ils)OIYLINER(afalieible)!'4:�s;,:+::::i:•:'.;>,
! ' / . C.^f41/ r// 76 FROM ft'
TjO/ ft-
D t]/E�rERi4o4I / i'.
THIC MATERIAL© ([7rG1 I p ' r1NNERCASIN •:X4 ;ii':.iv :i��'.-':tt"•.';:;:
2.Well Construction Permit#: r 611�3 2 ir1 FROM - To DIAMETER I .THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In l
3.Well Use(check well use): ft. ft. In:
WaterStlPP�Well: •17:SCREEN::�.....: =? a:�::i ;.`.°;ii,V'1'.:_'ti>:i:?r��:,,: ;:r`'. s•.:;.alih?;:.".M.i'i;:r.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0MunicipaI/Public 0 ft• it its
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. is
Industrial/Commercial Residential Water Supply(shared) _
:!t.?�18:GROUT;:ae' .'.:• `.:.'i::a; ': 1%,•i.?i:::: 1•Mie ZCksili::::`:i{•l'.
•:i4;;:fd.
. Irrigation FROM TO MATERIAL EMPLACE:ICE METHOD&AMOUNT
Non-Water Supply Well: 0 ft. .7 ft: ,o k j
Monitoring Recovery ft: ,fc glom)
� � � /
Injection Well: • r�l�:j1�',� /1�
Aquifer Recharge It. ft: !� 9r277'
Groundwater Remediation
Aquifer Storage and Recovery ID Salinity Barrier •`•19 SAND/GRAVEIGPAGIC(ifaPPli¢ible)};''{. 't F;'':is:f'iit:L'•c ,"•, is:R;:•z`•,.=>;-;: ;;;s';tg
�! lY FROM TO MATERIAL EMPIACEMENTMETHOD
Aquifer Test EiStcrmwaterDrainage f6 ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) }Tracer ';20:DRILL'ING LOG(attach additiiiiiil AEC If if riee`e hairy':e..i.: air i- .
. _ Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM To DESCRIPTIONeoiar. aess.sor0eoekhPe.train s¢.eta)
' 0 fa 41 P fa Pie-dui i' e.h/
4.DateWeli(s)Completed: f I ' t7'�,)WellID# / #41T ft. 14 7ft.. MP)/
^4/V T • _
5a.Well Location: , • �7,)ft' j. / L jAtAk 50G'-'E. J47f i7..
\1" ,1)/1/l rt91,4)//.-)W76- .ft. - ft. ,
FactldylOwnerName Facility1Dit(if applicable) ft. ft. I ••
19.c)p5' a hc. r,'j- DM1 jcl se iv QNy ft. ft.
Phy�}calAd City.and Zip • e' d' ' ft.. ,,....t� ..-_.. , ,„„,.,.--.. ./J/Jf �' 21:REiYIARKS:{ �_ : :•.r. ;+. r: .t
County . .Parcel Identification No.(PIN) Ct P h 1 iV )a/ i .7 ✓ iorp /. V�f
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: • • +,
(ii JdU S la,one la ong is�sumCient) ,b--��' i Is L.,�./
Jx �,/ ��J`/`f/�/) �J 22.Ce 'nation:
'/ N ��r / 88 w , ' K.
JAN 1 G C 4
Signature iff TWcll on ctcr
6.Is(are)the wells) Permanent or Temporary ° In,C,�,t zV c.n arac.,5 hg tiN,
r' By signing for
m,rm,I hereby certify that the well(s)t�R.4,t(d erigtructed in accordance
7 is this a repair to an existing well: JYes or-r�-I N with 15ANC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
(Mir is a repair,fill out known well construction information and erplatn the nature of the copy trf this record has been provided to the well owner.
repairunder#2I remarks section or on the back of this form. 23.Site diagram or additional well ditails: •
8.For GeoprohelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or welt
construction,only 1 OW-1 is needed. 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: '7 4d (ft.) 24a,For All Wells: Submit this font:within 30 days of completion of well
Fortm:110re wells list all depths lfdfferent(example-3Q200'end Ia100) construction.to the following:
10.Static water level below top of casing: Cp (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is aura casing use~ •1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C% G! (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
J?" )P1, � above,also submit one copy of this form within 30 days of completion'of well
22.Well construction method: 1/-r
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n/ - V 1636 Mail Service Center,Raleigh,NC 27699/1636
13a.Yield(gpm) � Method of test:/// . / / / / 24c.For Water Supply&Infection'Wells: In addition to sendi4 the form to
�j Li • // the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: l!77// Amount: .117. "" completion of-well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources Revised 2 22 2016
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