GW1-2022-03565_Well Construction - GW1_20220328

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WELL CONSTRUCTION RECORD(GW-1) Fo Internal Use Only:
1.Well Contractor Information:
0 S n 14.WATER ZONES
FRO TO DESCRIPTION
Well Contractor Name
IVl_YY(_ 430 ft. ft.
NC Well Contractor Certification
ilf t`Number
`1 \p [ 15.OUTER CASING Mir multi cased wells OR LINER if a livable
1 � ..1.{7 G� �O ft. TO I ft. DIAM�In. THICKNESS MATERIAL
Company Name D `G
16SXNNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: Fa0 SCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
htdustrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri ation FRM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R.�1QRa
t
Monitoring ORccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20. KILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FRC M ft. TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*� Lo ft.
4.Date Well(s)Completed:3�—OQ Well ID# ft' t ft' 'A C
t ft. ft. c
5a.Well Location:
1
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Physical Addres,City,and Zip ft. ft.
21. MARKS
aP_1Lt p-e
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertifieation:
N W ^
6.Is(are)the well(s) Permanent or Temporary Si ure of Certified Well Contractor Date
0 By s ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationXnaplain the nature of the f this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.q,ite 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-I is needed. Indicate TOTAL NUMBER of wells cons ruction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
h l
9.Total well depth below land surface: I�J^l D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') eons-.ruction to the following:
I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
abo e,also submit one copy of this form within 30 days of completion of well
12.Well construction method: N+11zL' N R� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
ivision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1�I`L7� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the ddress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: com letion of well construction to the county health department of the county
whe a constructed.
Form OW-1 North Carolina Department of Environmental Qi ality-Division of Water Resources Revised 2-22-2016