GW1-2021-03146_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW ll For Internal use only: 1 Print Foie
1.Well Contractor Information:
i4.WATER ZONES
Well Contractor Name ^ FROM TO DESCRirrION
Xk R. tt. P I
NC Well Contractor Certification Number } [ 0� ft. ft.
,,� I&OUTER CAUNG for could-cabred.waW 08 LIIYER le:c e i {�v(\++ 1��J¢+ FROM TO DIAMETER TBICKNESS MATERIAL
Company Name () ft. 4 % $0-W In. �
16.INNER CASING OR TUBING eothermof eloao f m
2.Well Construction Permit#: FROM f
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.fAC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL io
Water supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT Si7E TiHCKNESS I MATERI
Agricultural E)Municipal/Public ft. ft. is
Geothermal(Healing/Cooling Supply) esidential Water Supply(single) ft. th io
Industtial/Commercial Residential Water Supply(abared) 1&GROUT
FROM To TE -_- =EMt'LACPMENr METHOD&AMOUNT
Non-Water Supply WeA:___ _._ ____ _ .�rt t f .
Monitoring Reoov
injection Well: � � R'
fer Rec ft.
A9 in� �8e Groundwater Remediation
Aquifer Storage and Reno 14.SANDiGRAVELPACK to -
very �SatinityBarrier FROM To MATERIALJ EMPLACEMENT METHOD
Aquifer Test 13Stornwater Drainage ft. ft.
Experimental Technology Subsidence Control tt. th
Geothermal(Closed Loop) 13Ttacer 20.DRILLING LOG atfoh add douatsheeb if naxes
Oeothelntal eatin Coo' Rettmt other(explain under#22 Retnarks FROM To DEscRlrrroN rotor aduroetc eea
fk CAQ 4324 wain Awl r ft.
4.Date Wells)Completed:(A— tQ Wen I � )p eft. ft.
Sa..Well Location:
� ft.1a1rT , P r
Fae3lity/Owner Name Facility ID#(if applicable) N. R
C- cr oZ 3�0 fL
Phyi1cal Address, ity,and tip fL ft.
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one lattlong is sufficient) 22.Certification:
N
6.h(are)the wells PerDtanent or Tem ora W t tune ofCerti tad Well Contractor , � Date
) � p rY
By si this form,I hereby certo that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or 1No with A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown wail construction WbrmaNbn&n_Y=plaln the nature ofthe ,,fihis rernrd has been provided to the well owner.
repair under#2I remasssection or on the back ofthis form. 23.Site diagram or additional well details:
8.For GeoprobaMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
consttuctigm,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL VIST,RUCTIONSNS
9.Tatar wall depth below land surface: .% i
{ft.) 24a, For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells llat all depths 1fd(oerent(oomph-3(P00 and 2(a)100) construction to the following: C
10.Static water level below to of easing: ft
(l worer level is above casing,use"p' .
( ) Division of Water Resoureea,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For In(ectioa Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of tlhis`form within 30 days of completion of well
(i e.annger,rotary,Cable,direct push,etc•) CanStrECtian t0 the following: 7
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Al I 24c.For Water nnnly&inieetifon_Wells• to addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 186 completion of well construction to the county health department Of the county
where constructed.
I
Revised 2-22 2016
Form Ow-1 North Carolina Department of Environmental Quality-Division of Water Resources j