GW1-2022-09397_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
WATER ZONES 1 l Well Contractor Name FROM TO DESCRIPTION
2 65,ft 2�p ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LEVER-if a licable
FROM TO THI�CKDNESS MATERIAL
��mrN .l:1171�6 I` O rt 6�ft (� ;fir'R iD. �lJ�+ Z f !/C
ompany Name*`�1 16.INNER CASING OR TUBINGr eotbermal closed-loo
2.Well Construction Permit#: 3 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft• ft. in.
3.Well Use(check well use): ft• ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic R• ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft !in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GRUIIT
01r1'i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery tt v ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERW EMPLACEMENT METHOD
❑Aquifer Test ft ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL NG LOG attach additional sheets irnecess
FROM❑Geothermal TO DESCRIPTION color,hardness ETrock e, in sire,etc.(Heating/Cooling Return El (explain under#21 Remarks) Q
ft ft U a LQ—f CAp.-/
4.Date Well(s)Completed: 23 ft. g fQ 1 4- JA
Sa.Well Location:
2 rt. ft. Se+i v^.- !2
34�oIL RA
Facility/Owner Name ft. ft.
Facility ID#(if applicable) " r
ft ft r-
�b
G i o iP /C/1L Physical ft ft.dress,City,and Zip 721.REMARKS
County Parcel IdentificationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
6.Is(are)the well(s). 50PErmanent or ❑Temporary Signature or certified Well Contractor Date
By signing this form,I hereby ceri fy that the wells)was(were)constructed in accordance
7.Is this a repair to an ezoSting well: ❑Yes or f}N15' with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis 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#2I remarks section or on the back of this form. 23.Site diagram or additional well details:
8.Number of 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 construciran,you can construction details. You may also attach additional pages if necessary.
wells constructed:
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 34w (ft) 24a. For All Wells: Submit this'form within 30 days Of completion of well
For multiple wells list all depths ifdierent(example-3 00'and 2 100'
� @ ) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resol rces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Iniection Wells ONLY: lln'addition to sending the form to the address in
^�� 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:(i.e.auger,rotary,cable,direct push,etc.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
,3 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ���_ Method of test: 24c.For Water Supply&Injections Wells:
/6 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: &Zha well construction to the county health department of the county where
constricted.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 2013