GW1-2022-09383_Well Construction - GW1_20221010

vnur;r-vrrtr ;.
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Iitfbrmadon:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. 0 ft.
.3a 24-X Ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING formuId-cased weR9)OR LINER'if'a "R ble
/• � FROM TO DIAMETER THICKNESS MATERIAL
A ! Zo�r .L�. D ft ft. in.
Company Name 116.INNER CASING OR TUBING' eothermel:dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft• ft, is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FRO tl�E To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public G ft. FL in
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• ft. in,
Industrial/Commercial oReSidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO
Non-Water Supply Well: ft. 2 ft.
_:
` Monitoring _:Recovery ft. fit.
Injection Well: ft ft-
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACH H a liceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets Knecessa
Geothermal(Heatin Coolie Return) MOther(explain under#21 Remarks FROM TO DESCRIPTION(mlor,hardnesi4 soNroek etc
4.Date Well(s)Completed: 3.Z7 Well Em a. ft.
Sa.Well
�Location:
-J1�L.,:G1 �QG�� /?n✓l�f.S ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
Physical Address,City,and Zip A L5-5 7 ft. ft.
t2g 7�7� 21 RF.MARKR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc. • cado
r -�Qo / q
36 °�'In. Js2ZN 7R'p2) . 7" W 3a "!q ?-t3 -2-2
6.Is(are)the well(s) _Permanent or Temporary a e of Certifi a ontrt or Date
BY signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 0<0 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:
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1626 —(R•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the followin
g j
10.Static water level below top of casing: 0L) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+; 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter-_ (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
, - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 9/3 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -5 Method of test: the.For Water&p&&Injection Wells: In addition to sending the form to
address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: LizAmount: n c-L 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