GW1-2023-01751_Well Construction - GW1_20230223

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1'4:'F M R ZONES I I
— FROM TO DESCRD'T[ON
Well Contractor Name 9 ft, ft
�SyS - • ft. f
NC Well Contractor Certification Number 15rUT171ER•C SYl!TG'.for in lased wells Al 1,I1vER'if.a cable
FROM TO DIAMETER Tdif:IQYFSs MATERIAL
cc-tri �IS j atyud am V1 fr. 5 ft
Company N a CASING OIt 1. LNG- 'ed. ermal'c'osed-loo
/A FROM TO DIAMETER 71�CKNFss MATERIAL
2.Well Construction Permit#: AZZ—Ih VGS� ft fe. i tO
Gist all applicable well construction permits(l.e.UJC,County,State,Variance,etc.)
ft ft.
3,Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIC[OYESS MATERIAL
Agricultural .0Municipal(Pabile % fr liin
Geothermal(Heating/Cooling Supply) JBRtsidential Water Supply(single) fr, ft illn
IndustriaUCommercial Residential Water Supply(shared) is,G1i4Um
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation G ft rt r3•evr.�'a r �� -�
Non-Water Supply Well:
Monitoring Recovery fr, ft
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 10.SAND/GRAVEL RA. IC.I(a it aide.
Aquifer Storage and Recovery oS IA
alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
Aquifer Test tormwate
, 13t
rDrainage
Experimenial Technology i.. It E3S6sidence Control ft. ft
Geothermal(Closed Loop) OTraeer 20.- RMLIN LOG. tts d Itibnalsheet:If•netesso
FROM TO DESCRIPTION color,hardness saWrock slu etc
Geothermal(HeatingICoDling Return) nOther ex lain under#21 Remarks 0 fr• JC fr. I'
loll ft l J ft I'
4.Date Well(s)Completed: ( 'r�'�°2 Well� -
. ft. ft.
So.Well Location:
UC fr• _
C( G r �`
Facili /Owner a Facility ID#(if applicable) ft ft. I •y' tr'� ,
r l ft. EB
Physical Address, ,and Zip
�/� 2L RE ARKS
�r✓1 nrJ t/V e,I I �� Iflivi r%.i.;v:l •`•fir?ram,^.,.
County Parcel Identification No.(PIN)
�; eS�%iiQL"a
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if woll field,one lat/long is sufficient) 22.Cer ffication: }
3s , 7agG" N -$�. �ai�r6 W
6.Is(are)the well(s) Permanent or Temporary
e �' Signature of Certified Well Contractor` Date
_ or � _ By signing this form,J hereby cert✓fy that the well(s)was(rvereJ constructed in accordance
7.Is this a repair to an existing well: ®Yes No with ISA NCACO2C.0160 or 15A NCAC 02C.0200 Well Construction Siandards.and that a
Iflhis Is a repair,f it out known well construction Information and explain the nature of the copy ojthis record has been provided to the well owner.
rdpafr under#21 remarkr secilon or on the back ojthis form. 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 Geogrobe/DPT or Closed-Loop�ge6thvrmal 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:_ SUBIVII1TALINSTRUMM
9,Total well depth below land surface: 1 It, r VQ 24a. For Ali Wells: Submit this form within 30 days of completion of well
par multiple wells list all depths tfdVerent(example-3 r@200"and 2Qa l00) construction to the following:li
60 (ft.) Division of Water Resources,Information Processing Unit,
10,Static water level below top of casing:.,;, NC 27699-1617
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,
11.Borehole diameter: (ln•) 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, C1 d� construction to the following:` i
(i.e.auger,rotary,cable,direct push,etc,) Division of Water Resources,Underground injection Control Program,
,( 1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
('�'Q Method of test: Y- 24c.For Water Sunuly&II tectlon Wells: In addition to sending the form to
13a,Yield(gpm) the address(es) above, also 'subDut one copy of this form within 30 days of
n C t' completion of well construction to the county health department of the county
136.Disinfection type: r t ✓i Amount !�
where constructed.
Form OW-1 North Carolina Department ofHnvironmentai Quality-Division of Water Res urces Revised 2-22-2016