GW1-2022-09366_Well Construction - GW1_20221010

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_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cl 6 `?fl A� r� '14.WATER YONBS-Well Coat actorNani FROM •o DESCREM N
�. T1ft- �.
b ", 1 G-
NC Well Contractor Certificaation/lkTumber I5.OUTBdt CASIIV G; tie 'oB�misR - re
\4X�'e� W 1 y�,AI„�/� � FROM TO DIAMBTBR TH[CICIVBS4 MATERIAL
1 LV" V yl -+Y l ft. I Lry fl. in. 5G.
Company Name I6.INNER CASING OR TUBING elosed400
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
East all applicable well construction permits(i e.UIC,County.State.Variance,etc.) ft. ft. im
3.Well Use(check well use): ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSL7.B I TRICKINESS MATERIAL
Agricultural SWesidential
cipallPublio 0 ft. tt. in.
Geothermal(Heating/Cooling Supply) Water Supply(single)
Industrial/Commercial EIResidential Water Supply(shared) IS-GROUT
Irrigation - FROM TO TERIAL EWLa METHOD&AMOUNT
Non-Water Supply Well: fL "1 ft. 4
__Monitoring E31tecovery ft. ft.
1wection Well:
Aquifer'Recharge E)GroundwaterRemediation ft• ft•
19.SANDIGRAVEL PACK if licaMe
Aquifer Storage and Recovery [)Salinity Ban ier FROM I To I MATERIAL I E OLACEME U METHOD
Aquifer Test rIStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft, ft.
Geothermal(Closed Loop) OTracer 30.DRILLINGLOG attaeh additional dheetsifn
Geothermal(Heating/Cooling ,_Return) Other(explain under#21 Remaii;,$) FROM TO nFSCR>pTlorr(mror,>raiaa�,so0liuek a�
( � ft. ft.
4.Date Well(s)Completed: "Well ID# `1�_ "f 9 ft. ft.
Sa.Well Location: -I ft, ft. (. V
Fac(iliitty/OwnerName ! Facility IN(if appli/cable) ft. ft.
1 1 Sp Cw_ �C �` �gm a rG� INS/ 4�S% ft. ft.
,�
Physical Address,City,and Tap ft. ft.
21.REKAW
County a Parcel Identification No.(PIN) t'
5b.Latitude and longitude in degrmfminutes/seconds or decimal degrees:
ljgrl fiellone]latJlon ufficg is sient) 22.Certification: '
0 l'7y " N 7�o O� t 4 q /f W ..�� Ilk
6.ls(are)the wells) � Permanent or OTemporary Siguffore of Certified Well Contractor Date
4 signing this form,I hereby certify that the (s)was(were)constructed in accordance
7.Is this a repair to an existing well: dj;�',r E)No with 15ANCAC 02C.0I00 or I5ANCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out brown 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 diaglamor 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 1 GW-1 is needed. Indicate TOTAL NLJMBER of wells construction details. You may also attach additional pages if necessary.
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160 (ft:)
P 24a.For All Wells: Submit'ti»s form within,30 days of completion of well
For multiple wells list all depths if dtJferent(example-3Q200'and 2@100) f
construction to the following: ,
10.Static water level below top of casing: - (N Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �t{' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rOl V above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(Le.auger,rotary,cable,direct push,etc.) construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mall Service Center,Baleigh'NC 27699-16 6
13a.Yield(gpm) Method of test: U 4 24c.For Water Supply&.Infection Webs: In addition to sending the form to
the address(es) above, also submit one copy of this fbrm within 30 days of
13b.Disinfection type: MIA Amount: ®�A LDS completion of well construction to the county health department of the county
where constructed. I
Form OW-1 North Carolina Depa tmeutofEavimnmentd Quality-Division of WaterRisources Revised 2-22 2016