GW1-2022-07316_Well Construction - GW1_20220809

i
WELL C0N.QTDYLr' TON RECORD
This form can be used for single or multiple wells For Internal Use ONLY: 1
L Well Contractor Information:
l'Y vl J � 14.WATER ZONES
Well Contractor Name TO DESCRn'TION
33-7 �� 3 aft- 4
�- ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for math rased wens ORL1NER
FROM To if a 'cable)
DIAMETER TEICEMS
MATERIAL
fl(/ ft c—/
d.y N�arrreE"T 16.INNER CASING OR TUBING 'eothermal closed-loo
2.Well Construction Permit#:T, M ft.,ti p 3(, r 7 FROM TO DIAMETER rrffCKNEss MATERIAL
List all applicable well permits re County,Stteananft
a , ce,Infection,e )e i e to
3.Well Use(check well use): ft ft �•
Water Supply Well: 17.SCREEN
❑Agricultural
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑MunicipaUPubGc ft• ft fin.
❑Geothermal(Heating/Cooling Supply) 69esidential Water Supply ft ft in.
pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑hTi atioII 7 tt��=IALEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft•
❑Monitoring ❑Recovery ft ft
Injection Well:
ft
❑Aquifer Recharge ❑GrouudwaterRemediation 19.SAND/GRAVELPACK tfa 'cable
❑Aquifer Storage and Recovery ❑Salinity Bawer FROM To MATERIAL
EMPLACEhn;NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional,sheets if necess
❑Geothermal g/ g ) FROM TO DESCRn'TfON color,daraness,sai0roek e
(Heatin Coolie Return ❑Other(explain under#21 Remarks) ft 3 ft. s"`et`
_ 0 &.1
4.Date Wells)Completed: -02 -ZZ Well ID# Zd i% fl 3L• ' � ft �� ft
) `/CC lft. `S
5a.Well Location: o (� ft S, f4. Sp�fA
�06
ft ft
e �ca t'l7i n r� A n a`J 1r —2 n
l7G�
rac11Jty/q3WnerName ft fL
Facility ID#(if applicable) r^ °} B•.�
ft ft I—
n /
�1�'{f'q C f f 'l-b (qIA /-u . /" Jr /J Iccr
Ph stcal4.ddmss,City,and Zip ft ft.
— 21.REMARI{S
County
Parcel Identification No.(PIN) �ib:�'� •"'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:(if well field,one latnong is sufficient) 22.Certification:
N -6 D�� w •7
� Sign&MfifiskellContractor .6.Is(are)the well(s): `
HPermanent or ❑Temporary Date
By signing this form,I hereby cert#y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or pf�o with ISA NCAC 02C.0100 or ISA NCAC 02C'0200 Well Construction Standards and that a
#"this is a repair,fill out known well construction information and explain the nature oflhe copy of this record has been provided to the well owner.
f this form.
repair under#21 remarks section or on the back o .
23.Site diagram or additional well details:
S.Number of wells constructed:_ You may use the back of this page to provide additional well site details or well
For multiple injection or non-water supply wells ONLY with the same construction,you can construction details. You may also attach additional pages if necessary.
submit one form,
SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: C ©© (ft) 242. For All Wells: Submit this form within-30,days 00 of completion of well
For multiple wells list all depths##'different(esample-3@200'and 2
CJ � construction to the following:
10.Static water level below top of casing: titer
If water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
/ 1617 Marl Service Center,Raleigh,NC 27699-1617
r
(m.) 24b.For Infection Wells ONLY: Ins addition to sending the form to the address in
12.Well construction method:�_tr IJ+t 24a above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.
I construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tesh �o.tJ /wl 24c.For Water Suppiy&Injection Wells:
` Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county healtli department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 2013