GW1-2022-10005_Well Construction - GW1_20221104

I
'V41ELL CONSTRUCTION RECO (GRI- For Internal Use Only:
1.Well Contracfor•Information: j
t'tar+� al e-iomd r 14.WATER ZONES .
Well Contractor Name - FROM TO I DESCRIPTION
ftOft• Z'1+� ft.
(l
ft. is
NC Wed"Contractor Certification Number 15.OUTER CASING for mu16-cased wells OR LINER if a ticable
FROM TO DIAMETER ITHICKNESS MATERIAL
r&wn` rt. 2 rd-b Ker:5 TIC . ft ft in.
Company Name
( )� 16.INNER CASING OR TUBING eother al cloyed-too
2.Well Construction Permit#: 1 T FROM TO IDIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits O e.UIC;County,State,Yarianew etc.) it ft in' in i a- � _G
3.Well Use(check well use):, L ft. ft,• in•
Water Supply Well: 7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgriculturd aMunicipal/Public . ft• ft in_
OGeothermal(Heating/Cooling Supply) Rxesidential Water Supply(single) ft. ft. in'
❑Industrial/Commercial OResidential'Water Supply(shared) 18.GROUT
Oh1i ation . OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft z•2 I /' a vv+ wry.
OMonitoring ORecovery ft ft .�
Injection Well:
ft ft 1
OAquiferRecharge ❑Groundwater Remediation
19.SANDIGRAYEL PACK if applicable)
OAquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
OAquiferTest ❑StormwaterDrainage ft. fG
OExperimental Technology ❑Subsidence Control ft ft
I .;
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additidual sheets if necessary)
OGeothermai(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sai0rock in a' etc
ft ft.
4.Date Well(s)Completed:/a-s27;21 Well ID# fL ft
5a.Well Location: ft. ft
( L. } d
kip-rr%fte"!'- 4 L 176 fG fr. fr.
Facility/Owner Name++ ` r� Facility ID#(if applicable) .• ft. fL
t2 44! l rC0.1'�C!V 1 tA) .!J r 1 Jam- ff C ft ft j Pro czema l IBIS
Physical Address,City,and Zip GIs" ft. ft. MO"O0
21.ItEMARI{Si1~
_jrd E
County -J Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
3G° IT' ss-`t N B'1 to to ` �/3" e e w �.�~.•.--�� Ix"ZZ
6.Is(afe)the well(s): 0lfermanent• or OTemporary 1d Signature b Certified�WU o tractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 4No 15ANCAC 02C:0100 or1I5A NCAC 02C.0200 Well Cpnsrruction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of lk o.f 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 Closeii-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTTTAL INSTRUCTIONS
9.TotaI well depth below land surface: et�For multiple wells list all depths if different(example-3Q200'and 2Q100') (ft.) Submit this GW-1 within 30 day i of well completion per the following:
24a. For All Wells: Original faun to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing;use
tt-- i 24b.For Injection Wells:Co to D
11.Borehole diameter: (y �g (in.) Program,1636 MSC,Raleigh,NC 27699 63S derground Injection Control(ILTC)
12.Well construction method: r d'x+►fci ot'.it 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart'Tent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy WDWR,CCPCUA
'0 Permit Pro-gram,16 11 MSC,Raleigh,NC 27699-1611 a
13a.Yield(gpm) Method of test-
13b.Disinfection type: Amount: Jrc)Z
Form OW-1 North Carolina Department ofEnvironnrcntal Quality-Division of Water Resources v-•0^-'<<^^'"