GW1-2023-01780_Well Construction - GW1_20230223

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I WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: l
G _ i
1:4.'vIATERZONES l I
FROM I TO DESCRIPTION
Well Contractor Name ft. ft.
q5_4 5"A ft. ft. f
NC Well CogtmctorCertification Number 1S, C11FER•CA3IIIG.for•inW �eesed ivblls OR INER'1fg cable
J ," FROM TO DIAMETER THICIOMS MAURL1L
4 fG I� ln. 0 � L
Company Name , } 6.•)ATNE '_CASLMGORTRIHING- edthermgl'clobed-loo
2.Well Construction Permit#: V 3 O 0 3 1 EOM To DIAMETER TiUL;Kn ss MATERIAL
ft. ft. �
List all applicable well construction permits(t.e.WC,County,State,Variance,etc.) i
ft. ft.
3.Well Use(check well use):
- 17.S'O EN
Water Supply Well: FROM To DUMETER SLOTSIZE THiCiWESS MATERIAL
Agricultural OMynicipal/Pilblic ft. fr. i,�
Geothermal(Heating/Cooling Supply) nl r`gpidential Water Supply(single) ft. g,
Industrial(Commercial Residential Water Supply(shared) 18.G1t UT t
Irrl ation FROM TO MA ITERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � fr' o�-a fr' eri Y>,1
Monitoring Recovery ft. ft.
Injection Well: ft. ft. -
AquiferRecharge GroundwaterRemediation 19,SANll/GRAVEL PACK(Ifapplipa le.
Aquifer Storage and Recovery oSelinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
`Aquifer Test �'' s'-�Stormwater Drainage ft. ft.
•.:i'1;�� ¢�
�! '�'•! [)Subsidence Control ft. ft.
Experimental Technology �.,t,,l is
Geothermal(Closed Loop) E3Traccr 20.PFMLTNrLOG. ttaeh dtUHbnal.abeet:(f necessa
FROM TO DESCRIPTION color herdnes'soWrock size ale
Geothermal(Heating/CoolingRattan Other(explain under#21 Remarks fr, fr• i rfi G
4.Date Well(s)Completed: Wetl ID# ft.
f I'
So.Well Location: I ft `>..r��5:`4;f
Facility ID# ifa applicable) ft. fr. I LE 6) r D
Facility/O Her Name tY (• pp• )
fL
Physical Address City,tip fr' nra,. `Ill
`` 21.REMARKS
tieY -i-a�
County Parcel Identification No.(PIN) -
Sb.Lr'titude and longitude in degrees/minutes/secontjs or decimal degrees:
(if wall
�field,
.lone lat/long is sufficient) (, L 22.Certification: i
W I 0
Signature of Certified Well Contract , Dato
6.is(are)the wells) ermauent or [3Temporary.
By signing this form,i hereby certo that the well(s)was(were)constructed In accordance
7.1s this a repair to an existing well: E)Yes or %No with 15A NCAC 07C.0100 or ISA NCAC 01C.0d00 Well Construction Standards and that a
If this Is a repair,fill out known well construction►glormatlon and explain the nature of the copy of this record has been provlded to the well owner.
•rdpalr-under-#21 remarks section or on the back of this form._ 23.Site diagram or'addltional well details: -
8.For Geoprobe/DPT or Clostid-Loop;Geothermal Wells having the same You may tine the'back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'-Indicate TOTAL NUMBER of wells
drilled: r� I' SUBMITTALiNCI'RUCTIONS
9.Total well depth below land surface: a< 'i (ft) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(Jferenifexarpple-3 200"and 2@1001 consttuction to the following: I'
10.Static water level below top of casings' 6 b (fr-) Division of Water Resources,Information Processing Unit,
If water level is above casing use„+" I 1617 Mail Service!Center,Raleigh,NC 276994617
11.Borehole ditimett r: (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
�J above,also submit one copy of Ibis form within 30 days of completion of well
12.Well construction method:_ I�b � construction to the following:
(U.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) Method.of test: � 24c.For Water Sunnly&Injection Weirs: In addition to sending the form to
the address(es) above, also submit one copy of dus form within 30 days of
13b.Disinfection type: 6L-k10"rl K2 Amount: CAW 5 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