GW1-2022-01912_Well Construction - GW1_20220224

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor I o .
o r n Z", 1L WATER ZONES
Well ContractorE FROM TO DFSCRD'TION
R R .
v R R
NC Well Contractor m r®ber 'I&OUTER,CASING. for QRLRYER ti€.
caft
FROM ro DIAMETER THICIt� MALE L/
fL ( C` R in.
Company Name / ^_ J
(}J( 16::I .�:tiS1NGflR.177BIIv�:
2.Well Construction Permit#: FROM TO DIAMETER I TMCKNESS MATERIAL
List aU applicable well construction permits(Le.U1G County,State,Variance,etc.) R R iu.
3.Well Use(check well use): R in.
Water Supply Well: FROM To DIAMETER'. SLOTSIZE THICU MESS MATERL►L
Agricultural 13Mtmi blic 0 R fL in
Geothermal(HeatinglCooling Supply) GJV5idential Water Supply(single) R m
Industrial/Commercial 13Residential Water Supply(shared)
,,18t OITF
Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R Q fL D
CVA 0-CA
d V�
Monitoring DRecoveiy R R
Injection 'Yell:
R f4
Aquifer Recharge [3Growidwater Remediation 19,.SANDIGRAS'EL`PA£B
Aquifer Storage and Recovery �$alutity Barrier FROM TO A MATERIAL I EMPLACEMENT METHOD
Aquifer Test' 13Stormwater Drainage R
Experimental Technology E)Subside=Control R
Geothermal(Closed Loop) Tracer 38, .. :.LUG..att &=W&MAI aBeefsi
Geothermal eatin Cool' R ) Other(explain under 421 Remarks FROM TO D ON wlor, soiUrock she etc
R � R (-r
4.Date Well(s)Completed: Well ID# S� R p ft. J c
Sa.Well Location: R R
�_ R R
Facility/Owner Name C Facility IDS*(iifffaWlcable) R R
fL fL J r�/t !t //u✓can
Physical Addoim City,and Zl fL R
cl-e)za n 21 REMARKS BMW"
County Parcel Identification No.(PIN) 1:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,oneWong is sufficient) 22.Certification:
N W I � a2
6.Is(atre)the welts) ermauent or Temporary Signanne of Certified Well Conaactor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and char o
tf this is a repair,Jill out known well construction Ufermation and explain the raturs of the -PY gfdw record has been provided to the well owner
repair roller 921 rrmanis section or on the back of thisform. 23.Site diagram or additional well details:
S.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 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /�0� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: % (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftbfferent(ezm iple-3@2 'and 2@1001 construction to the following:
10.Static water level below top of casing: `S (R) Division of Water Resources,Information Processing Unit,
If water level,is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter. (in) 24b.For Injectiou Wells: In addition to sending the form to the address in 24a
12.Well construction method: D ✓`�
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger.rotary,cable,di—push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test %7 1 09W 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 (6 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7-1/ Amount: /6 L_ completion of well construction to the county health department of the county
where constructed.
I
Form OW-1 North Carolina Aepaumum of Environmental Quality-Division of Water Rescurc I Revised 2-22-2016