GW1-2022-03649_Well Construction - GW1_20220328

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WELL CONSTRUCTION RECORD(OH-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name ft ft.
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NC Well Contmetar Certification Number 15.OUT.ER.CASING:for.muM.!,c- -edWiU RIII R =p ncable
FROM TO DIAMETER TLDCLtNEM
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Company Name 16.'J NNER C7ISING OR..... G euthermal cluseddao _
5 � � FROM TO THICKNES � MATERI
2.Well Construction Permit#: DIAMETER S AL.
_ ft ft is
List all applicable well construction permits(i.e.UIC,County,Stile,Variance,etc.)
3.Well Use(check well use):
Water Supply Well: FRont To DLAMEI'ER sloT sLZE TmcLavess MATERIAL
OA cultural ❑Mlmicipal/Public Ott. it In. t f0 j C� b G
OGeothermal(Heating/Cooling Supply) pesidential Water Supply(single) ft & to
OIndustrial/Commercial OResidential Water Supply(shared) I -Ggp
MOM TO MATERIAL EMPLACE M>,T80D&AM U1V'r
plrri lion —. OWelis_>100,000 GPD nr, o20it.
Non-Water Supply Well: l/
OMonitoring ❑Recovery ft ft
Injection Well: ft• iL
OAquifer Recharge ❑Groundwater Remediation 19;5AND/GRAVEL YACIf a cable
OSallnt Barrier FROM To MATERIAL ElytpLACEryIENTpiErHOn
❑Aquifer Storage and Recovery tY _
❑Aquifer Test ❑Stormwater Drainage 35� ft ft 6Ave�p�, CeMe
IJA
oFxperimental Technology OSubsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer
20:DRIILINGLOG attach'additionslsheetsffumS
FROM TO DESCRiP'rION wlo,hardness,solidc.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft Q f. �+Q
4.Date Well(s)Completed:
3 Lq L Well1D# ft M
ft ft.
5a.Well Location:
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Facility/Owner Name Facility iD#(if applicable)
it. ft
X ft ft
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Physical Address,City,anoe
6-/-_V-7 21 REMARKS r ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certificalio .
35b�z, &I N �� a �3t W z
Si ofCcrtifiedWen �NCAC
tor
6.Is(are)the well(s):Nermanent or OTemporary
si ing this farm.I hereby cthat the well(s)it-as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No MC 02C.0100 or 15A 02C.0200 Wdl Construction Standards and that a copy
Ifthis is a repair,Jill out known well construction information and explain the nature nfthe of this record has been provided to the well owner.
repair under#21 remarks 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 construction info
(add,Sce Ove!in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (23.80 00 Submit this GW-1 within 30 days of weH completion per the following:
For multiple wells list all depths if dderem(example-3(a3200'and 2Qa 1007
24a For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: U r ru 24c.For Water Supply and 0 eu-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producini over 100,000 GPD:Copy to DWR,CCPCUA
(� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) (( Method of test: