GW1-2021-07430_Well Construction - GW1_20210921

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2.Well Comstructlon P C•'S FROMERfCASDNG:OR}TUB>DIAMETER � MATERIAL
r stint#: fQ � lam.
List all�ipplleable well conshucNon permits r.e.UIC,Coun K Van etc:)., n• tt in.
3.Well Use(check well use): ft tt ( is
Water Supply Well: . aViSE Fgoty . TO DIAMETER, sLOT sI7E THICKNESS MATERIAL
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❑Agricultural ❑Municipal/Public 2 ft I%, Ze
❑Geothermal(Heating/Cooling Supply) 'residential Water Supply(single) ft tt in
Olndustrial/Commercial ❑Residential Water Supply(shared) 1&KGROUTaNEENW,
01rrigatidn ❑Wells>100 000 GPD FROM TO MATERIAL EMMACEP4ENT NnrMOD e AMOUNT
Non-Water Supply Well: O tt. ft Y
+' ❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
,a9.4SAND/GRAVEL&A- k J66111a eWWI
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test OStormwater Drainage ft 3-P
OExperimental Technology ❑Subsidence Control ft. R
OGeothermal(Closed Loop) ❑Tracer a20hDRII1LING;LOGIith`ebVddidbit7d?ibap`if,aaea
OGeothermal ea' Coolin Return OOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn sotVtoeli etc
fL ft
4.Date Weil(s)Completed: _ Weu ID# tt. n
Y /�,5a.W u Lyocad n: R
e/7G� //` !< ft. j
Facility/ er Name Facility lD#(if applicable)
ft. It.
,,��yy,, ft. ft.
Physi 1 Ad City,and Zip �_ R R•
,- Y-sS2�? u,20RE ARKS
imty Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwweqell field,one latnong is sufficient) 22.CertIfl on:
^J�� �� 53 1, N 7" w
6.Is(are)the wells): ermanent or ❑Temporary oi'Cestified Weil Comractor Date
By signing"form I hereby certify that the xpll(t)xns(were)constructed in accordance with
7.Is thin a repair to an existing well: ❑Y¢$ OrVO 1 SA A'CAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction biformation and explain the nature of the of thus record has been provided to the '•ell 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 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.
dolled: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Lev, 2 3a (ft)
For mula'pk wells list all depths!f different(example-3@200'and 2@100) Submit this GW-1 within 30 days of weB completion per the following:
Z D• 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (B) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Boreh�le diameter: 7 (in.) Program,
For Injection Wells:Copy to DWR,Underground-Injection Control(TUC)
I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well lonstruction method: 24c.For Water Supply and Oven'-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health delatizYent of the county ere MOW
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells proctor lit over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount: c.� Z 6
Form OW-1^ North Carolina Department of Enviromnentfil Quality-Division of Water Resources' ' Revised 6-6-2019