GW1-2023-00737_Well Construction - GW1_20230113

Pont Farm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
s
1.Well Contractor Infjor do I:
t(e I / e r4.VWAT R NESOM TO DESCRH'TION
Well Contractorr Namr, ft. ft.
ff' D'
NC Well Contractor Cartificetion N bar : UTER•CA811t1G,for•in :eesed'wells O)t LAVER if a cable
FROM TO DIAMETER THICENESS MATERIAL
�� � s e11 d- Pumn ft. �q ft. ,/z5� sbR r
Company Name (j I6.' CASIlVCy OR T edlliermaFo osed-loop)
2.Well Construction Permit#: f 1 FROM TO I DMMTER TIUCICNESS MATERIAL
List all applicable well construction permits Q.e.UIC,County,State,Variance,etc.)
ft, ft. In.
ft. ft. �•
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICXNESS MATERIAL
Agricultural 13Municipal/Pabiic ft. ft. to
Geothermal(Heating/Cooling Supply) �kgsidential Water Supply(single) ry, ft. In.
IndustriaUCotnmercial Residential Water Supply(shared) Pit
EN
ROUT
irrl 8tI0n PR OM TO MATERIAL EMPLACEMT METHOD&AMOUNT
Non-Water Supply Well: k C/ ft r f367: 5
Monitoring Recovery ft. %
n ectiou Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 10.SAND%GRAVEL PA IE,itjapplieft le.
Aquifer Storage and Recovery OSalinity Barrier FROM j TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test , [3StormwaterDrainage 1t IL
`i
Experimental Technology `•,��: Subsidence Control
ft. it
Geothermal(Closed Loop) Tracer 20.-DRILLING LOG Iattta@h d Itlbnaleheet:ifnecessa
FROM TO DESCRIPTION eo�lor,hardness eoufrock size etc
Geothermal Heatin Cooling Return Other(explain under#21 Remarks) Ly fL qtt.
4.Date Well(s)Completed: ,� "� Weti ID#
fL ft
So.Well Location:
ft
AnrL 1I art
r r ft.
Name Facility!D# if applicable) k' s
.�
Physical Ad ss,City,and Zip
o K 21.ItEMARKS
County Parcel Identification No.(PEN)
Sb.Latitude and longitude In degrees/minuteslseconcjs or decimal degrees:
(if wall field,one lat/long is sufficient) 22.Certification:
r
3S 901 0 8 N g2, 118�5 w
Signature ofCertified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary BY signing this form,!hereby cent fy that the well(s),vas(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or 0 with 11A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
pi t
Ifihis is a repair,Jill out known well construction information and explain the nature ojthe edgy ojthts record has been provided to the well owner.
rdpair under#21 remarks section or on the back ojthis form. 23.Site diagram or additional well details:
Closed-Leo" hi the You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or p Geiithcrmal Wells same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed:'Indicate TOTAL NUMBER of wells
drilled: `L $yJ311 ECUL i1YS 1 RUCTIONS
9.Total well depth below land surf&ce: (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lldeerent(example-3(200"and 2@1007 construction to the following:
10.Static water level below top of casing:..' f0 urces,Information Processing Unit,
� (ft.) Division of Water Reso
ljwater lavel is above caring,use 1617 Mail Service Center,Raleigh,NC 27699-1617
1 i
11.Borehole diameter: `>L (�•) 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: Q construction to the following:
(i.e.auger,rotary,table,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
t
13a.Yieid.(gpm) Method of teat: /r 24c.FQater SuDDIv&Infection Welds: in addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: C ti]n ri rt Amount: °L C 5 completion of well construction to the county health department of the county
where constructed.
Farm OW-I Nortb Caroline Department of Haviromeantal Quality-Division of Water Resources
Revised 2-22-2016