GW1-2022-10563_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
• 4
1.Well Contractor Information: j
-14.WATER ZONES T
Well Contractor Name FROM TO Ft. DESCRItrr[oAT
(_.// t of ft.
NC WellComractorCertificationNumber 25ODTFdtCA3mtG' -cis 5fe 'UHIm6R" esb7e
� T i FROM TO DIAMSTBR THIC[CNM MATERIAL
V V/ -Z� C!IS, _l/h 4.1 ft. ft in.
Company Name I6.DINER CASING OR TQBING elosed o013)
2.Well Construction Permitffi: FROM TO D THICKNESS L MATERIAL
List all applicable well construction permits(i e.Uia Cawuy.State,Variance,etc) fL I in.
3.Well Use(check well use): (L ft. im
Water Supply Well: FROM TO DIAMETER S1,037Sn+.6 I THICHNPSS MATERIAL
Agricultural C)Mtmicipallpublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft. ft, ;o
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
Irrigation - FROM To MATERIAL EMPLAcMdMT METHOD&AMOUNT
Non-Water Supply Well: ft. `�o 0-
:-31vlonituring E3Recovcry M fL
Wection Well:
t't. Et.
Aquifir'Recharge E)Groundwater Remediation 14.SANDIGRAVEL PACK If 6 P PV--ble
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EatPLACBMENr METHOD
Aquifer Test [3Stormwater Drainage fL fL
Experimental Technology nSubsidem Control ft, fL
Geothermal(Closed Loop) Tracer 20.DRII.IdNG"LOG attach additional sheets if necessary)
10cothermal(Heating/Coolin Return) _ Other(explain under#21 Remarks) FROMI TO DESCRD?TION(colon so,-Urock etc,
ft. fL
4.Date Well(s)Completed: ' -7,2v2 well ID#00 ft. ft.
t
Sa.Well Location: ft' fL F'~ ` �' "
6-0,(!l 1A LA t e—) ft. ft.
Facility/Owner Name FacilirfM9 Cif applicable) ft. ft'
ft. .smg Un4
Phh�pi.d Address,City,and Tap —� /j ft. ft.
1'!:ry` 1 k�,� h /�r l� -'t'j ,- j� 21.RnIARBS
County a PametIdentifirationNo.(PIN) %-iv �or -e�
5b.Latitude and longitude in degrees/minutedseconds or decimal degrees: C'a�
(ifwaltfield,one lat/longis sufficient) 22. cation:
N ? 021' �13 W S / —
6.Is(are)the well(s) rmanent or OTemporary Signafirm of Certified Well Contractor Date
/ By signing this farm,I hereby certify that the weA(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Me' or [3N6 with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construdion Standards and that a
ifthis is a repair,fill out brown well construction information and explain the nattrre of the copy of this record has been provided to the well owner.
repair tuder#21 remarks section or on the back.of thisforin.
23.Site diagram or additional well demos:
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 OW-1 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: V (ft) 24a.For AR Wells: Submit this form within 30 days of completion of well
For muUiple wells fist all depths if different(example-3Qa 200'and 2@100) construction to the following:f
10•Static water level below to n -
P of� = �` ) A) Division of Water Resources,Information Processing Unit,
If water levei is above casing,use I" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Iniectiou Wells: In addition to sending the form to the address in 24a
��k �� above,also submit one copy,of this form within 30 days of completion of well
12.WeR construction method: 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 Ma11 Service Center Raleigb,NC 27699-1636
13a.Yield(gpm) On Method of test: ) 24c.For Water Supply&Wection Wells: in addition to sending the form to
ff the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l� Amount: completion of well construction to the county health department of the county
where constmcbed.
Form GW-1 North Carolina Quality-Division of WaterResouaces Revised 2 22 2016