GW1-2022-08705_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informed n: J
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FROM TO DESCRIPTION
Well Contractor Name
ft.
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NC Well Contractor Certification Number a= n;
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n01 5 i�/Gf C1� _/ V� 6G� uP1 FROM TO DIAMETER
• THICKNESS MATERIAL
tr YVl I- t C] h fL j ft, 6 r11!J in. VV
CompanyNa a �y
2.Well Construction Permit#: -G2 G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.U1C,County,State,Variance,etc.) ft. tt. In.
3.Well Use(check well use): ft.
IMM
Water Supply Well: FROM I TO I DUMETER SLOTSiZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) fL tt. In.
IndustriaUCommercial DResidentiai Water Supply(shared)
1 1rd ation FROM TO KATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
Monitoring Recovery ft. tt.
Injection Well: ft. rt.
n Aquifer Recharge GroundwaterRemediation 40ir
Aquifer Storage and Recovery Salinity Barrier FROM TO + MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OStibsidence Control
Geothermal(Closed Loop) Tracer "Il';I) tit�:f.'.e`e;o.'1 d .0` "IYAWN I,titie {.
Geothermal eetin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color hardoess soll/rack role sl ate.
rc. I Q rLC a
4.Date Well(s)Completed:0 /154ZI Well iD# 13 ft. 505 ft' C9 tA vi,i _ _ -
So.Well Location:
Gwli iliaCA Vk�'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
37 0 0C V"V-` VV Or
Physical Address,
ACity,,�and
/Zip
/V 1 (i 1/ V •�' L I I 7K
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35,&75G4 N '-aI •��oa7 W � -
6.is(are)the wells)JoPermanent or OTemporary Signature ofCenified wall Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: Owe or MNo with 1JA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standmds and that a
If this is a repair•Jill out known ivell construction IgloMation 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 ojthisjorm' 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SiJBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5b (ft-) 24a. For All Wells: Submit!this form within 30 days of completion of well
For multiple wells list all depths(/different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing:_.- (ft.) Division of Water Resources,Information Processing Unit,
tfmter level Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: to.q (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
r_ r� above,also submit one copy of this form within 30 days of completion of well
O
12.Well construction method: 4-rA construction to the following: '.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: I r 24c.For Water Supply&Iniection ells: 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: 11 Amount: 2-C"t-'P.S completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016