GW1-2021-08162_Well Construction - GW1_20211109

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Prjnt foi'frl
WELL CONSTRUCHON RECORD(GW 1) For Intemal Use Only.
1.Well Contractor Information: i
z _la WATER 2ANES
Well Contactor Name FROM TO I DESCRWnON
'
IL ft.\1V it ft.
NC Well Contractor Certification N er ;pTrF1 ►gDIG-(for aiultt rated{rims"OR LINER n" ea6fe
\ !'1tOM 1'O DIAMETER I CK`NESS MATERLtII�MD .
R R it
CompanyNamc ^ eeyy
6:tNNEI CASING OR TUSiNG
2.Well Construction Permit#:�._ FROM to DIAMETER: liltClrivESS me3Enrer
List a0 applicable well eonstnrdion permits rt a UIC Cow*State.Variance,da) R. R la.
3.Well Use(check well use): R R in.
Water Supply Weil: 1TSGREEN _
FROM TO DIAME[BR SLOT SIZE ..,TRIMNESS .TiE'RIAL
FN:
tural []M ipal/Public R 19,SA in 1=11'� �0 V�
mal(Heating/Cooling Supply) esidential Water Supply(single) R R in.
al/Commercial 13Rcsidcntial Water Supply(shared)
-'1&'GROUT n FROM TO MATERIAL EMPLACEMENTMEMOD&AMOUNr
er Supply Well: R. Ring Recovery R RWe1I:'- R R Rechchame QGroundwater Remediation 19 SANDLGRAVEL PA d>a 'eabte -
_`Agnifer Storage and Recovery Salinity Batrier FROM To MAMIAL EMPfACKMENT METROD
Aquifer Test [3Stormwater Drainage EL it
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer =2&DR[CLING.LOG attaeh'addi6enalaGEets'ifi `.,77
Geothermal(HeatingfCooling Return 0thcr(explain under#21 Remadrs FROM To D�cRlnlox edor aardne�s wa/roelc stoor,etr
R O R
4.Date Well(s)Completed Well E D# Lk7JLR l
R5e1 ovation: R R
R R
Famlit�y/OwwnerNaame Facility M#(ifapplicable) ft. ft.
5r�is—� Aae- idft IL
/NFhysical Addrcss,City,and Zip ft. ft. �, ( / I f`, [I-
WE -. •�
21:REMARKS r:;(
County Parcel Idctttifi�iott No.(PIN) NOV
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ifwciroficid Ong�issufficient) 22.Certlfcation: i
..�,nn+,mil r) I :N ��r :•� �
N W ;
bt
6.Is(are)the well(s) -Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify,that Ire xe/1(s)nms(were)oohs—ed m accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Consintedon Standorda and that a
6 this is a repair,fill out Arrmvn well construction information and esplain the moue afthe copy ofthis record has been provided to the well owner.
repair under 021 remarks section or on the back ofthisform.
23.Site diagram or additional well detar7s•.
&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: (fL) 24s.For All r Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd ffererri(emmp/e-3@2000 and 2@100) construction to the following:
10 Static water level below top of casing: ! (R) Division of Water Resources,Information Processing Unit,
If nester Level is above casing use"++ �� 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. . (in.) 24b.For Iniection WeOs: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �j\��A construction to the following:
(1.auge,rotary,cable,direct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
((WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm)� L J Method of test 24c.For Water SDDDIv&lniectioni 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: Amount completion of well construction to the county health department of the county
whew constructed.
Form OW-1 North Carolina Department of Environmental Quality-DivWon of Water Resource; Revised 2-22-2016
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