GW1-2022-07315_Well Construction - GW1_20220809

ALL C®NSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
f� -7 ft' ' ft. / f
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for mutti-rac` ed wells OR
FROM TO f.INER rf a licable
DIAMETER THICKNESS MATERIAL
ompany Name 16.INNER-CASING OR TUBING eothermal dos
2,Well Construction Permit#: ,Z— // FROM TO DIAMETER THICLQVE$S MATERIAL
List all applicable well permits(i.e.County,State,variance,Injection,etc.J ft % p tn.
3.Well Use(check well use): % fk
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNFSS MATErtrA1❑Agrictilttual ❑MunicipaVPublic ft
❑Geothermal(Heating(Cooling Supply) gresidential Water Supply t
pp y(single) f
❑IadusttiaVCommercial OResidential Water Supply(shared) 1S.GROUT
❑Im ation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Well: ft• Z J ft
❑Monitoring ❑Recovery FL ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Grormdwater Remediation 19.SAND/GRAVEL PACK rf a tic able
❑Aquifer Storage and Recovery ❑Salinity gamer FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑•pincer 20.DRII.LiN0 LOG attach additional sheet-if necessary)
FROM TO DES TION -for,hardness,soiUrodc G
❑Geothermal(Heating/ 'ooling Retu m) ❑Other(explain under#21 Remarks) ID ft � ft Ae•eta)
4.Date Well(s)Completed 7-v2 7-2Lyyep ID# ft' fk I,Gp
ft. 4{d ft.
Sa Well Location:
��t.i1t•� c n 1, ft fL
Facility/Owner Name ft h
C 1n Facility ID#(ifapplicable) ft ft.
Ph7ioal Address,City,and Zip ft ft.
1,`(S t 21.REMARKS
County Parctifidentification
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: Intofa '''
(if well field,one fatllong is sufficient) 22.C • ation: -
4 _
6.Is(are)the well(s): ❑Permanent or ❑Temporary Si -lure of Certified well Contractor Date
By signing This form,I hereby certify that the well(s)was(were)constructed in accor nce
do
7.Is this a repair to an existing well: ❑Yes or ❑No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number nj wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construc8on,you can
submit one form SUBMITTAL INSTUCTIONS
R Total well depth below land surface: 2"�� r (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths ifdifferent(example-3Q200'and 2 00
- l C3� 3 constriction to the following:
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 2 Processing
il.Borehole diameter: /�l
(in.) 699-1617
24b.For Iniection Wells ONLY: hi addition to sending the form to the address in
12.Well construction method 24a above, also submit a copy of this fora within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.
o Ila � � construction to the following.
y `
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
? 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gPm) to Method of test• 1>�o w 0U m• ^ 24c.For Water Supply&Injection Wells:
` Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013