GW1-2021-00108_Well Construction - GW1_20211109

WAJL L 1;4.lAb l Rut-11un 1CJC.tL,tl rw For Internal Use ONLY:
This form can be used for single or multiple wells
1.Welt Contractor Information:
T M' 14.WATER ZONES
.1 J I 15 FROM TO I DESCRIPTION
Well Contactor Name ft. 6 ft. 141 2 7 b
3 P
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a Ilcable
FROM TO DIAMETER THICKNESS MATERIAL
r;I�l-hj2 p ft Sz it 6157 in. /2s (J C
Company Name 16.INNER CASING OR TUBING eotherrnal closed-loop)
2 FROM TO DIAMETER i THICKNESS I MATERIAL
2.Well Construction Permit#: • O `l' ` M ft. in,
List all applicable ivell construction permits(Le.County.State,Parlance,etc.) ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA IETER I SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Weesidential Water Supply(single) 1G ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL F-MPLACEMENT METHOD&A,YIOUNT
❑irri ation o ft 90 f` cdetil ou c
Non-Water Supply Well: it. ft.
❑Monitoring ❑Recovery
Injection Well: ft. [t
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if u livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11L tt-
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRII,LIIVG i:OG attach additional sheets if necessary)
❑Geothermai(Closed Loop) ❑Tracer FROM I TO DESCRIPTION tor,nnrdness,solurock typC jz=ln size,Or-)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) R. ft. Q v
�l
4.Date Well(s)Completed: d -` A I rL ft SA e
5.Well Location: O ft. Ot d ft 4t4 eA
ft 13,
Fility/O er Name �jFacility ID#(if applicable) R. ft
AV A. r 4�LA��(jM 1�&Ilu fL ft
Physical Address,City,and Z'p 21.REi11AItKS
UsU;l�o�
County Parcel Identification No.(PIN) DWR SECTION
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: -INFORMATION
(ifwell field,one latllong is sufficient)
35 T, 7b'UI�N 36 . ,2 '7 3;- 96 q 3S w
Si re of Certified Well Contractor Date
6.Is(are)the well(s): kfl�ermonent or ❑Temporary By signing this farm.1 herebv certify that the ivell(s)was(were)constructed in accordance
,� with 1 SA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: �tYes or ❑No copy of this record has been provided to the well owner.
lfthis is a repair,full mu known well construction information and explain the nature of the
repair under#21 remarks section or on the back-of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or iron-ivater supply wells ONLY ivith the same construction,you can 24.Submittal Instructions-
submit one form. t
9.Total well depth below land surface ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3®200'and 2 100') ( construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,Information Processing Unit,
/f water level is above casino,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
!11.Borehole diameter: 24b.For Iniection Wells: In addition to sending the form to the address in 24a
(in•)
� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: %] t construction to the following:
(i.e.auger rota cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�_ �(j%_ 24c.For Water Supply&Geothermal Wells: in addition to sending the form to
13a.Yield(gpm) Method of test:_�[L the address(es) above, also!submit one copy of this form within 30 days of
/T 1 completion of well construction to the county health department of the county
13b.Disinfection type: /'7 / �7 Amount: !U S where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013