GW1-2021-07375_Well Construction - GW1_20210921

mal Use Only:
WELL CONSTRUCTION RECORD(GW-1) For lute y:
1.Well Contractor'Information:
IJS to �tIb
Well Contractor Name FROM I TO DESCRIPTION
�l3 6r+ 201� ,J
NC Well Contractor Certification Number
IS OUTER`CASING"r for- ;Dx ORdINLtR tf:'_:';
O FROM I TO DIAMETER, THICKNESS MATERIAL
�+ ft156 ft iir i
C Name
7 t•�.�,�. i6;=1NiiIER:+CASIItIGORif�TBiNGt ", "; �'�, ,;,<
2.Well Construction Permit#/: 3J5'1� 1 FROM TO D I TMCKNM MATERIAL
List all applicable weft construction permits(i.e.UIC,County,State,Variance,etc) & fL I
3.Well Use(check well use): ft, fc in.
a7._SCRB
Water Supply Well: EN_,
FROM I TO DIAM= I SLOT SIZE ^I THICKNESS I MATERIAL
cultural [3MunicipaVPublic 0 fL ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL
Industrial/Commercial 131tesidential Water Supply(shared) 1S GROU'T. -t..µ
Irrigation FROM TO MATERIAL; EMPLACEMENTMETHOD&AMOtNT
NOD-Water Supply Welh fa W R,
Monitoring Recovery ft, fe
Injection well:
:c f<
Aquifer Recharge Groundwater Remediation
Jo &SANDIGAAVEL `'`PACK rf', bi .={
„ .
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I,.EMPLA09kU fTlMEIROD .
Aquifer Test oStormwater Drainage & ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.1 DR1I 1 LNG LOG:atseeh addiaoaal sheets it
Geothermal Hoatin Coolie Return Other(explain under ff21 Remarks) FROM TO DESCRIPTION color,hlydnes4 eoiurecE
a lL & Said ;
4.Date Wels(s)Completed: W 20 7-1 Well LD# T 91 ft
Sa Well Location: ft fL
1J 0 A cif A H & it.
Facility/Owner Name Facility M9(if applicable) ft fl, es�t
i22q S La
Physical address,City,and Zip Ln�G�oh &
County P—1 Identification No.(PIN)
�.
5b.Latitude and longitude in degrtes/minutes/seconds or decimal degrees:
(ifwe11 field,one lattiong is sufficiem)
22.Certification:
N
6.Is(are)the wells) 1OPermanent or Temporary rgnaturo o e ed ell ontractor Dde
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7-Is this a repair to an existing wtn: 13 Yes or EYNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnrctian Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
[/ ,✓ SUBMITTAL 2LS RUCTIONS
F Total well depth all
lowdepths
sand surface:7�( (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list act depths if different(example-3@100'and 2@100')
` construction to the following:
If
fwaterlevet is above casting,use"+10.Static water level below top of casing. U {ft} Division of Water Resources,Information Processing unit,
11.Borehole diameter; O
1617 Mail Service Center,Raleigh,NC 276"-1617
(in,)
24b.For Injection Wells; in addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/ 1636 Mail Service Center,Raleigh,NC 276"-1636
13s.Yield(gym) Method of test:�� 1101 24c.For Wa er Supply&In)ection'Wells: In addition to sending the form to
13k Disinfection type: Amaant l the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Dep
artment of Environmental Quality-Division of Water Resources Revised 2-22-20I6