_Well Construction - GW1_20230310 (44)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�,I( 1'4:'l('ATER.ZQHES j�rl-e/J'�r Oa d FROM TO DESCRIPTION
Well Contractor Nam% fry M j
ft.
NC Well Contractor Certification Number 15, .G.for•inul :eased welly 0ALINER'if a cable
FROM OC1PER•CA TO DIAMETER THICKNESS MATERL►I
' ft. ft. l2 �• h 2 VC
Company N a 6.'INNE '"C 11VG Q T G 'edtlierm'el'•cTosed-loo
2,Well Construction Permit#: ' y FR To DATER 1lI1cI0VESs MA ERIAL
List all applicable well construction permits(i.e.CAC,County,State,Variance,etc.)
tL rt. �•
ft. ft.
3.Well Use(check well use):
17.SfJ EN
Water Supply Well: FROM TO DIAMETER SLOTSIZE TIHCIOYESs MATERIAL.
Agricultural OMurticipaUPublic ft. ft, t°
Geothermal(Heating/Cooling Supply) 1�Rgsidential Water Supply(single) ft, ft, ini
IndustriaUCatnmercial Residential Water Supply(shared) la,.tli UT.
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Im ation
Non-Water-Supply Well: G ft ft.
Monitoring Recovery fr." ft
•
Injection Well: ft. ft.
:.)Aquifer Recharge Groundwater Remediation .'19.SAND/GRAVEL PA. K l(a Uca'le"
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft 1t
,fit)�,
Experimental Technology a i1FSubsidence Controlft. ft.
Geothermal(Closed Loop) [3Tracer 20.'DRILLIN LOG. ttaeb' d tibnal.sbeet tf necessa
FROM TO DESCRIPTION color hardness aoWrock size etc.
Geothermal(Heating/Coolin
g Retturn) Other(explain under#21 Remarks it. ft, a L
4.Date Well(s)Completed:Vim/ �'Ireu w# , f 4 I �5 ft. rCt r T
. rt. ft.
5a.Well Location:
ft. fr.
��lity/Owner Name Facility ID#(ifeppficable) f6 ft. A ; ��• .
Faci =Y0.�tLv cc, CIV, V'� C� ra ft.
r,A t
Physical Address,City,and Zip
TZ71� 21.REMARKSOff C&S
County Pascal ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seeonr(s or decimal degrees:
(ifwe0 field,one lat/long is sufficient) (� �ICertlfi Hon:
35,3 -1, `t� N . 05 1013 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s)19Permanent or E3Temporary"
By signing this form,!hereby cert�y that the well(j)was(tiara)constructed In accordance
7.Is this a repair to an eilsting well: E)Yes or .No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Srmrdardr and that a
IjtMa is a repair,Jill out known well construction Information and explain the nature of the copy ojthls 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:
S.For GeoprobelDPT or Closed-LA Geothermal Wells having the soma You may use the back of this page to provide additional well site details or well
4p: construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed,•indicate TOTAL NUMBER of wells
drilled: /d SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 U CJ (ft) 24a: For All Wells: Submit this form within 30 days of completion of well
par multiple wells list all depths ljdlfjerent(example-3@200"and 2@1001 construction to the following:
10.Static water level below top of essino" (ft.) Division of Water Resources,Information Processing Unit,
ljrvater level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dfa&aet r: (in.) 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; d l — 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 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 20 Method of test: /T t y- 24c.For Water Suoaly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1✓t a Amount: completion of well construction!to the county health department of the county
where constructed.
Form OW-1 North Carol Department Dtment ofEnvirOwwntal Quality-Division of Water Resources Revised 2.22-2016
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