_Well Construction - GW1_20230310 (61)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
�m VPC,
1.4:'V('AI R.ZOHES
FROM TO DESCRIPTION
Well Contractor Name ft fL
ys A & %
NC Well Contractor Cortificatiou Number 15.-O)OTE1t•Ci1SING.tor•in :cased wells ORIMR-(ifap llcable
FROM TO DIAMETER THICKNESS TERIAL
�,�C1dMA�1 s �N21 l G►Ae� ��>'w►/r� it. 11ro ft A S in. S ' �,�'
Company a 16.• ER.CASING ORT G• edthermml'•c►'osed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits Q.e.WC County,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1 Well: 17.SiE1tEEN
Water Supply Y FROM TO I DIAMETER SLoTSiZE_I THICKNESS MATEIUAL
Agricultural [MunicipaMblic ft. ft. in
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) g, ft, in
IndustriaUCommercial DRosidential Water Supply(shared) 18..Ck•.UT
Irr1 ation FROM TO MATERIAL
TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 h' V ft. L
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation• 19.SANK/GIYAYEL PACK lt;a licadle.
Aquifer Storage and Recovery., ,\ [Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ,� "•, [StormwaterDrainage ft. fa
Expetimerital Technology ;�.``a'�}A? Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.,DRiLLIN LOG. ttaeh it Hpnal.sheetsafuetesea-
FROM TO DESCRIPTION color,hardness soWrock typN grain size etc
Geothermal Heatin Coolil!n,,g Retum) Other(explain under#21 Remarks V ft. t O ft. of
4.Date Well(s)Completed:V /''"' Well ID# ft. 1 05 ft' Y+I
ft. ft.
5a.Well Location;
w l.f ft ft.
Facility/Owner Name an Facility iDff(if applicable) ft'
Cl 6-1? S ho r_*Ck � &w V—e�v�r`t c ft. ft. MAN , -
Physical Address,City,and Zip ft
fw�I L A 21.REMARKS
+J ``r•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
35 t'Z731I N �i t�t3 559 W ` ul&� �3 3
6.ls(are)the well(s) Permanent or [Temporary
Signature of Certified Well Contractor Dat
" BY signing this form,!hereby cert(fy that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: ®Yes er gj1Vo with I SA NCAC 02C.0I00 or i5A NCAC 02C.0200 Well Construction Standards and that a
If this/s a repair,Jil!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 thls farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed=Igop;Geothcrmal Wells having Use same
' construction details. You may also attach additional pages if necessary,
construction,only I GW-I is needed. Indicate.TOTAL NUMBER of wells
drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 C) 8; 00 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jdifferen((exarlrple1-3@200"and 2QI00� construction to the following:
10.Static water level below top of casing; 1�© (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Infection Wells: In addition to sending the form to the address in 24a
�� N� above,also submit one copy of this form within 30 days of completion of well
12.Well 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 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) & Method of test: 1 24c.For Water Supply&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: n�,_ Amount: G' S 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