_Well Construction - GW1_20230310 (55)

Print Form.
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
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1.4:'V('ATER.7ANES
FROM I TO DESCREPTiON
Well Contractor Nam@ ft. fL
ft. ft.
NC well Contractor Certification Num r 19.-0VT&R.CA81f!IG.for•inul *cased ivbM)OR ifs U R' llcsbie
n n FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.' R CASING OR7 ' G 'edtherm'el'olo3ed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits O.C.WC,County,State,Variance,etc.)
(t, ft. In.
ft. ft. �•
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOTSIZE TMUMIFSS MATERIAL
. .Agricultural 0MunicipaMblic ft. ft. !n'
Geothermal(Heating/Cooling Supply) fft@sidential Water Supply(single) ft, ft, In
Industrial/Commercial DResidential Water Supply(shared) 18..OR' UT
IA
Itri ation FROM TO MATERL EMPLACE TMEMOD&AMOUNT
Non-Water Supply Well: n ft ft he BNl-h2 6 r S 5
Monitoring Recovery ft. fL
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SANDIGRAVEL PACK 1t`a N able.
Aquifer Storage and Recovery Salinity Barrier FROM I TO KATE I EMPLACEMENT METHOD
',�•�••Aquifer Test .;,��; [3StormwaterDrainage fL ft.
Experimental Technology 1,1t11} Subsidence Control It. fL
Geothermal(Closed Loop) Tracer 20.5D MLiN LOG.attae7r'additional sheet:if aecessa
FROM TO DESCRn TION color hardaeaa aoWrack alze etc.
Geothermal(Hestia Coolie Return Other(explain under#21 Remarks ft. ft -Y
4.Date Well(s)Completed: �^ — Well ID# D fL 6 ft' t -7-
5s.Wellll Location: 11ft. ft.
7 DIJe� l �Y up. 411
D
Facility/Owner Name Facility ID#(ifappticable) ft. ft. Z023
�— fL ft.
1 o�J �o►()tl>� ��� Codes � '� b _
Physical Address,City,and Zip
lje I 21.REMARKS
County ( Parcel Identification No,(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(if well field,one lattlong is sufficient) 22.Certification:
� 9 S�oq N -�1. 661�5 W
6.Is(are)the wells) armament or Temporary
Signature of Certified Well Contractor 61
Date
By signing this form,1 hereby cerlo that the well(j)was 6vereJ constructed in accordance
7.Is this a repair to an existing well: [3Yes or &No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,Jill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
•rdpair under#21 remarkr section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed=Loo;Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
p construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / SUBMITTALINSTRU—M-0 S
9.Total well depth below land surface: UQ 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijd fferent(exagrple-3@200"/and 2@100) construction to the following:
10,Static water level below top of casings- /6 (fL) Division of Water Resources,Information Processing Unit,
if water level is above casing,use 11,11 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dtan e°ter: (ln.) 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: Y`d / �V V construction to the following:
(i.e.auger,rottay,,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �2 Method of test: Q-f V 24c.For Water SUDDIV&Infection Wells: In addition to sending the form to
�7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 1 ti? Amount: L V,12 completion of well construction!to!the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016