GW1-2023-00992_Well Construction - GW1_20230118

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well C/gptractor Information:
14..WATER ZONES
FROM TO DESCRIPTION
Well Contractor Namtt ft. ft.
q,4s-A
NC WeU C,punc tor Certification Number fff��� /1 ' J,'.-OIJTER•CAS .G',foram ti�ca9ed wbUs OR LINER'irB liceble
�,w� p ^ (/�r�- t FROM TO DIAMETER THIC�Q ' MATERIAL
t.
Company Name 16,'1NNEli:.CASIIVG UR'TUINNG� edttermal•o fosed-Ioo
2.Well Constructiou Permit#: (� bt�Y Q_ n�� FROM TO DIAMETER THICKNESS MATERIAL.
Us(all applicable well construction permits Ae.f11C County,Stat,Variance,eta.)
ft. fL tu-
ft. ft. �•
3.Well Use(check well use):
1,SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSUM THICKNESS MATERIAL.
Agricultural OMuaicipaMblic ft. ft. In-
Geothermal(Heating/Cooling Supply) [residential Water Supply(single) fr fr, hL
Industrial/Commercial Residential Water Supply(shared) 1s..iROUT
IITI 8tlen FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
6 fL '��' Ot�Y L
Monitoring Recovery fr• ft
Injection Well: It. ft,
Aquifer Recharge [3GroundwaterRemediation EMSAND'X;tELRA4`K..If•e itcaBe
Aquifer Storage and Recovery : DSalinity Barrier M TO MATERIAL. 111111EMPLACEMENT METHOD
DAquiferTest [3StormwaterDrainage It.
to
:.... tt, fa
]Experimental Technology r. Subsidence Control '
[DGeothetmal(Closed Loop) Tracer 20,'DRILLINGLOG. ttacb 8.itibnal:sbeet:if•aecessa
FROM TO DESCRIPTION color,hardness sol0rock size eta
anal(Heating/Cooling Return) _Other(explain under#21 Remarks) I ft. fr
to ell(s)Completed: r 1 Z-'A Well IlD# ft ft. ...•s
ft. ft. R
Sa.W Location:
�t ft. fr. A
Fnility/Owner Name FaFil ty ID#(if applicable)
(O �/ ft. fr. i414Oft+ft2 iWl PrW Umit
r ll// t 1�rrALed fr. fr
Physical Address,City,and Zip
13 �Ke- ... ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minuteslsecono or decimal degrees:
(if well field,fonee laillong is sufficient) 22.Certification: +�
Signature ofCertified Well Contractor Date
6.Is(are)thewell(s) rmanent orTemporary
By signing this form,1 hereby certo that the wells)was(were)constructed/n accordance
7.Is this a repair to an existing well: [DYes or RNo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
/f 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.
re?alr under#21 remarks section or on the back ofthls form. 23.Site diagram or additional well detalls:
You may use the back of this page to provide additional well site details or well
8.For Gcopro6e/DPT or Closed-Loop'Gstithci mat Wells having the same
construction details, You may also attach additional pages if necessary,
construction,only 1 GW-1 is needed.•Indicate TOTAL NUMBER of wells
drilled: >_ =_ SUBMITTAL R TRUCTIONS
9.Total well depth below land surface: J YQ 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple)vells list all depths Udgerent(exa(pple-3@200"and 2@1001 construction to the following:
10.Static water level below top of casing:t` 21 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaler level is above eating use„+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (h1.) 24b.For Infection 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, U(a Y l construction to the following:
(i.e.auger,rotary,cable,direct push,etc,) '
Division of Water Resources,Underground Injection Control Pragratn,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Y[eld.(gpm) Method of test:, - 24c. Wells: In addition to sending the forn to
r Water Supply&Inlection
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: G 6_K�h Amount: G�L completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Enviroameatal Quality-Division of Water Resources
Revised 2-22-2016