GW1-2021-06575_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Info ation:
14..WATERZONES"
Well Contractor N e
FROM. TO DESCRWTION
W /\ ItO rt U2. rt ft' I : fgnt Pe_
t7 _
NC Well ContractorCertificationNUri
. 400 ft 401. f*e
1./ IS.=OUR.CASING,foruttc�ased;wel4"=ORtIIQEtt a lienhte =
�C y�� IROM TO DIA11iE1ER' THICKNESS MATEBiA[
Company acne IIN 1 ft. 34 ft ln. S R.21 PvG
7
G/t i•16::'IW%M CAME ORTQl3I11iG(eo(hei'mal elosed-loo'
2.Well Construction Permit#: 3605 78' FROM TO I DUMETER THICKNESS MAURML
List all applicable null construction permit(7-e UIC Como,,State.Variance,eta) R• D• in.
3.Well Use(chec(rwell use): ft. it in.
Water Supply Well:
FROM TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural [] MunicipaUPublic ft. iZ is
Geothermal(FIcating/Cooling Supply) &1identiaMaterSupply(single)
R ft. in.
Industrial/Commercial OResidential Water Supply(sherd) a&:GROUT
Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fti
Monitoring DRecovery
Injection Well: % ft.
Aquifer Recharge DGroundwater Remediation _
39:SAND/GRAVEL-P,kCK'ffe-li&bl'e
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 8• ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) 07 acer 20:ARt1AMGLOG(attachffaddiiieral;sheersifnecessa
Geothermal(Heating/Co in Return Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,softaek in shD—etc.1
�. Zq
4.Date Wells Completed: 4/ Z ft- ft.
O P • � weulD# _ _ - 30 300 (' 61vr? tan;l'-e
5a.Well Location: 301 ft• 780 ft. fe ran i
IW/i lliam R_ Talley n. ?~
Facility/OwncrNamc - Facility lD#(ifapplicable) R• R•
In (eves Hills Radix! Lolnsiha NC, 71roI �' �
Physical Address,City,and Zip ft. . ft
6-le- (t29W-too 20
County Parcel Identification No.(PIN)
t.•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Vv-
(ifwcH field,one lat/long is sufficient) 22.Certification:
N w ajgLIWEV 27 2I
6.b(are)the well(s)UPermanent or OTemporary OWture ofCettifi d Well Contractor Date
,By signing this form,I het+eby certz1v thai the nvll(s)was(were)constructed in accordance
7.Is this a-repair to an existing well: Dyes or EaCo with 13A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy,ofthis record has beenprovided to the ivellowner.
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 site details or well
construction,only i GW-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: 790' (fW 24s:For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3@200'and 2 a@100) construction to the following.
/� r
10.Stack water level below top of casing: -Zl�d_ (tt) Division of Water Resources,Information Processing Unit,
Ifxater level is above casing,use"+^ t� 1617 Alail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (m.) 24b.For.Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: •� /10►f y above,also submit one copy of this foam within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (' L 1636 Mail Service Center,
ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test± l� j)'! 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of -
13b.Disinfection type: Amount: aZ completion of well construction to tihe'county health department of the county
where constructed.
f
Form OW-1 North Carolina Department offinvironmental Quality-Division of WaterResouraes Revised 2-22 2016