GW1-2022-08308_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor InformL)ation:U //
•14.WATERZ0NFS`: :.'1.:
WellContractorName nn T FROM TO DESCRIPTIIN
� a J' U —�i' '�/�6 it. s�� it
ft. ft.
NC Well Contractor Certification Number AS.'OUTER:CASING formiilticasEdwelL4 OR'LINER►fa"livable ';'.::;;'';::::•:;;"
c�P Y Name -y ncL FROM TO DIAMErER THICKNESS MATERIAL r_ Ji ra
Com an _ �� ft ft. io.
ft/`c
16.HOER'CASING ORTUBING:'eiitbciviel¢1med-lou dt�l= ;':;;ii 3=. '.!a
2.Well Construction Permit#: FROM - TO DIAMETER THICKNESS - MATER1Ai,
List all applicable well construction permits(le.U1C,County,State,Variance•eta) ft ft In.
3.Well Use(check well use): ft ft in.
Water Supply Well: WSCREENss:'s::'s:€:
FROM TO Di BWER SLOTSIZE I TMCKNESS^. MATERIAL .
Agricultural ElMunicipaUPublic U ft ft In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft to
:)Industrial/Commercial bfQdential Water Supply(shared) .�18 GROUT:: r:;: _
hri ation FROM TO MATEitrAL EMPLAMUMMETHOD&AMOUNT
`
Non-Water Supply Well: ft ft
Monitoring Recovery ft it
Injection Well:
Aquifer Recharge E)GrotmdwaterRemediation ft ft
A uiferSto Storage Salini Barrier 19 SANDIGRAVELPACK tfiibili abie%:,:
tl Recovery tY FROM TO MATERIAL EMPLACEMMTMEMOD
__ AquiferTest EiStormwater Drainage ft ft.
. Experimental Technology Subsidence Control it ft
Geothermal(Closed Loop) E3Tracer .10MRILLINGLOG ettaehsdditl6n dliNitsifiieeessa'
. Geothermal(Heating/CoolingRetum) Other(explain under#21Rematics) ltoM To DFSCREMON(eo)or.Lardacs%soWmck •'"ya•eta)
ft &
4.Date Well(s)Completed: —2—Well ID# / ft it iJ6 ul Sa
5a.WeRLocation: G ft
- t n tz• U/lF.e /�I�y/�e'7 ft. & / P.
Facility/OwnerName _ Facility IDil(ifapplicable) v it• Q ft• y n': uIP• '
�2�2,'a//�vi�;v L f �� �'lZ�t�,` d�tF d it. jrTO it r Aa.- e J ' r
Physical Address,City.andZ- 4 "� ft. ft _
—
County t Tamel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification: f/3;T(S Qi'`S,S.5G yy N ` y s.a
6.1is(are)the well(s)�ermaneut or OTemporary Si eofCertified tractor Date
� By signing this form,I hereby eert�that the rvell(s)tvas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or S110 with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis Is a repalr,fill out hnotm well construction Information and explain the nature of the copy ofihfs record has been provided io the well owner.
repair under921 remarks section or on the backofthisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or on
Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2e) d (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For-1147le welts list all depths/#different(-ample-3@100'and 2 a@100) construction to the following:
10.Static water level below top of casing: �KL7 00 Division of Water Resources,Information Processing Unit,
Ifwater levelly above casln&use•'+" 1617 Mal Service Center,Raleigh,NC 276991617
11.Borehole diameter: ��,, (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Well construction method:
above,also submit one copy of this form within 30 days of completion,of well
(ie _!'��A��/ie.auger.rotary.cable,diceet push,eta) construction to the following:•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) —Method of test: �. 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type:G Amount: S. >_.0 completion of'well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016