GW1-2022-03584_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor f n:
14 WATE—ZONES
Well Commctr time
FROM TO DESCRIMON
/ ft. ®fL R R
NC Well Contractor on Number
15..0UTER:CASDIG for. wdW OR LINER
FROM TO DIAMETER THICItTiESS MATE
fL I - iv C
Company Nam / 16c1NNESf:C�1.SINTG OR TUBING:
2.Well Construction Permit#: FROM I 1 ,4 TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(Le. ,Cormty,State, nee,eta) R fL in.
3.Well Use(check well use): R ft in
Water Supply Well: FROM
FROM TO DIAMETER SL01'SiZE THICKNESS MATERIAL
Agricultural pMlmic" lic 0 fc fL in.'
Geothermal(Ileating/Cooling Supply) idential Water Supply(single) IV R m
Industrial/Commercial [Residential Water Supply(shared) Our ..
Irrigation FROM TO MATFdtIAL EMPLACEM METHOD&AMOUNT
Non-Water
Supply Well: h- Vr ft. V a v
Monitoring Recovery ft. ft.
jection Wen:
n
Aquifer Recharge 13Gmundwater Remediation
19.SAND/GR&-VEL'PACK '. le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' 13Stormwater Drainage fz
Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) Tracer 38•�RII,LIiYG:.LUC..aa.chaddifleaot eSeett;
eatin Cool ) Other( lain under#21 Remarks FROM TO DESCRD TWN color, smyrock sae,eto
4.Date Well(s)Completed: J �.� o� ell ID# ft ©� & GL(
5a.Welllocation: / ft ft
& fL J\Ir t d .r)
Facility/Owmiy Name /) Facility W#(ifaWlicable) fL f<
C f/r/ MAR 2 S 2022
Physical City. ;4 & fL
.:21-REMARES
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degma/minates/seconds or decimal degrees:
(ifwen field,one lac/long is suffeiem) 22.Certification: nn
W y i1—
6.Is(are)the well(a) ermanent or Temporary Signantro of Certified Well Contractor Date
By signing this form,I hereby certify thin the well(s)was(were)constructed in accordance
7.h this a repair to an existing wen: ©Yes or o with 15A NCAC 01C.0100 or ISA NCAC 02C.0100 WeU Consv=aan Standards and rhat a
tf thus is a repair,PU out brown well construction it formation and explain the nature of the copy ofihis record has been provided to the well owner.
repair under s2/rernarla sworon or on the back of this form. 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. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ /0 0 00 241. For All Wells: Submit this form within 30 days of completion of well
For mulapk wells&I all depths ifdfferew(exmnpk-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: ( 0 (fL) Division of Water Resources,Information Processing Unit,
lfwarer level is above casing,use +/ 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b.For Infection Wens: In addition to sanding 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: f,•, n construction to the following:
(i.e.auger.rotary,cable,direct push,etc)
Division 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 tat: _ 24c.For Water Supply&Iniec`tion Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: G ��!! Amonnt: completion of well const uction Ito the county 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