GW1-2021-08161_Well Construction - GW1_20211109

i
WELL CONSTRUCTION RECORD(GW 1) �� ° s
For Internal Use Only:
.Wd1 Contractor nfo ratio
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d _
Y4',WATERZONEB
11 Contrrac�to�r Name FROM TO Dy+SCltTp7 tON
ft. R
NC Well Connector Certification Number fL ft.
rZ'OUTERCASING.for'aiottf wsedw`"dlls'ORZiNElt ' a' to
kwoM To D I'ER THICKNESS 1LttIAr
ft. t' fL % 1 tm, ,
Company Name I
A&_INNER;CASING_OR:1t)BING'
2.Well Construction Permit#: d '
�.. FROM TO DIAMETER' THICKNFSS :.: MATERIAL
List aAapplicable hell construction permits(i.e.UIC,County,State Variances eta) ft. ft. ill
3.Well Use(check well use): ft. fL In
Water Supply Well:
Agricultural �M pa!/Public FROM To DIAMETER ISLOTst THICKNFSS TERtnI j4
l�' in
Geothermal(Heating/Cooiing Supply) esidential Water Supply(single) fL tt in. �
IndushiaUCOMMCMial DResidcntial Water Supply(shah d) ,,
FROM TO MATERIAL fiMPLACEMENTMErBOD&AMOUNT
Non-Water Supply Well: s R. ! ft. i /• / I,
Monitoring Recovery
Injection Weil:
Aquifer Recharge [Groundwater Remediation ft. fL
Aquifer Storage and Recovery Salinity Barrier 49.SAND/CRAVEti`PAC%:da'' L'csbte
ON MATERIAL EMPLACEMEN f ME Aquifer Test E)Stormwater Drainage fL fL TROD
Experimental Technology [Subsidence Control L
ft. ft,
Geothermal(Closed Loop) OTracer 20.DRILI:INC IsOC_attse5'addltroiwi streets=if
_ Geothermal(Heatin Cooling Return) ` Other(explain under#21 Remarks) OTO DSSCRIP110N nco ,aillnek etL
4.Date Weff(s)Completed: 1 Well ID# R
A
58%F-ifity/0vwm.aZNa.me
Well Location: It R
e B R
Facility M# if aap�plicable) ft ft.
R. ft G..: ..
Thysical Address,City,and Zip it fL
i, =2I REINARKS -
County Parcel Identification No.(PIN) "
5b-Latitude and longitude in degrewminuteeseconds or decimal degrees:
(if well field,one lat(long is sufficient)
G e 22.Certification:
6.Islam)the wen(s) ermanent or 13Tempor•ary Signature ofCertrfied Weil Contractor Date
7.Is this 8 repair to an w�; B'signing this form.I hereby—,try that the i ell(s)was(were)conshucted in accordance
eAding QYes or with ISA NCAC 02C.0100 or I54 NCAC 02C 0200 Well Construction Stondandv and that a
lfthis is a repair.jlll out known well c0=ftction mformatton and erplain the nature afthe eopy afthu record has been provided to the%ell owner.
repair-der#21 remarks section or on the back ofthis 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 1 GW-1 is heeded. 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: 00 24a. For All Wells: Submit this form within 30 days of lction of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q1003 comp
construction to the following:
10.Static water level below top ofcasing:- \�
Ifwater level is above caWng,use'•. (fL) Division of Water Resources,Information Processing Unit,
� 'F1 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: n� U^� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_l V ;L�� �� above,also submit one copy of this form�within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 'T�--- construction to the following.
FOR WATER SUPPLY WELLS ONLY; i Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) C Method of lest: 24c.For Water Sm iv&Infection Wells: In addition to sending the form to
` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1�l Amount: completion of well construction to the coiutty health department of the county
where constructed. i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016