GW1-2022-04053_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GA-11 For Internal Use Only:
1,Well Contractor Informa on: 14.\A m WATER ZONES
FROM O DFSCRIPTION
FROM
Ii wenContracttoorName R' I f 1!ryo
a'G^i ) ft. ft.
NC Well Contractor Certification Num er 15.OUTER CASING for'multi-ensed wells OR LINER if ticable
TU
DMA R THICKNESS MATERIAL
FROM
r� In.
Company Name I6:INNER CA ING OR TURING 'eotbermal cltiCKNEo J%L4TERi L
h •� FROM TO DIAMETER THICKNESS
2.Well Construction Permit#: � " " 1 ft. n• In.
List all applicable well comtrt/etion permits O.e.UIC,County,State, ariance,etc.) ft. ft in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public tt. fL in.
Agricultural
Residential Water Su i (single)
Geothermal(Heating/Cooling Supply) pp y g
IndustriaVCommcrcial Residential Water Supply(shared) 28.GROUT MATER L E[itPLACEMEIVT oD AMOUNT
FROM TO
'11nigation 0. ft. 6 ft. -
Non-Water Supply Well:
Monitoring
Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Retnediation 19.SANDIGRAVEL PACK if a iicable
�+�,Sallni Barer FROM TO MATERIAL EMPI.ACEMF.NTMETHOD
Aquifer Storage and Recovery Salinity ft. tL
Aquifer Test C)Stormwater Drainage
��••�},Subsidence Control
Experimental Technology jJ
Tracer 20.DRILLING LOG.attach addiflonal sheets if aeees
{ s
Geothermal(Closed Loop) iJ FROM TO DFSCItiP iTON color kacdn solVrack a in a etc.
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks)
` ft.
Date Well(s)Completed: I 3 Well 1D#
ft. ft.
5a.Well Location: 4 ft. n• 1
Facility ID#(if applicable)
Facility/ nerName ft.
ft.
-
Physical Ad s,City,and Zip 21.REMARKS
Parcel Identification No.(PIN)
F sy . ;1
County 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
('Ifwell field,one laViong is sufficient)
N R' "r
�S_ignatqr of Certified ell Contractor Date
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certify That the x�ll(s)was(were)constructed in accordmice
7.Is this a repair to an existing well. Yes or dNo wirh 15A NCAC 02C.0100 or 15A PICAC 02C.0200 Well Constrncnon Standards and that a
copy of this retard has been provided to the uvil owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this fibrin• 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details to well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
constructipn,only 1(}W-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL�STRUCTIONS
drilled: 1
9.Total well depth below land surfacer (f t') 24a. For All Wells: Submit this form within 30 days of completion of well
For muitiple ivells list all depths if dtI erent(example-3@300''and 1@1001 constmction to the following:
10.Static water level below top of casing:_ � (ft) Division of Water Resources,Information Processing Unit,
)f ivater level is above casing,use"+" 1617 Man Service Center,Raleigh,NC 276994617
11,Borehole diameter: (in.) 24b.For Injection Wells: Tn addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
]2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
E
SUPPLY WELLS ONLY: J/
Method of test• 'uu 24c.For Water SupDIY&Injection Wells: In addition to sending the form to
Yield the addn�s(es) above, also submit one copy of this form within 30 days of
Amount:. completion of well constniction to the county health department of the county
type: a4 where constructed,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22 2016