GW1-2023-02724_Well Construction - GW1_20230411

WELL 4CONSTRUCTION RECORD For Intemal Use Only:
1.Well Contractor Wormation:
14.WATER ZONES
--r�sName '��e�v DESCRIPTION
]FROM •�
WeaCoatraetorldame '1 (� R. S ne f
ft.
NC Well ContractorCerdficationNumber IS.OUTER CASING for multi-cased wells OR LINER tre 1lcable I
i VROM To E
Ant a TMCKKE3s MATttRrAr.
CompanyNamo 16,INNER-CASING OR•TUDING eothamal elosed400
FROM TO DIAMETER THICKIY MATE RIAL
2.Well Constru�tlon Permitt ?k9_';e99A,r2- �o D Gq tL >e In.
List all applicable ivdl construellan peraritr(Le.WC Cortno.Xatg Variance,eta)
fp tG la.
3.Well Use(checkwell use):
17.SCREEN
Water Supply Well: FROM TO DIAMtt:rER SLOTSUK THICtt2iP3ii MATERIAL
OAgriculturai .[3M ug{cipaUPublie 3 R, 6 ft. In. l2�
OC=thermal(Heatiog/Cooling Supply) tdeatial water.Supply(single) n ft. 1m
-'Ol'ndustrial/coulmercial ❑Residential water Supply(shared) I8 GROUT
01ritigation .DWells>10000DGPD FROM To MATERIAL E11PLACEMEYrMLTHob&AHowr
'NOD-Water Supply Well: _ b' O R'
-- C]Monitoiiitg:- i r --- dRecavery ft•
jecdoti•Wel1p�' it. ft.
OAqusPec.RechatgQ...- :` 30mundwater Remediation 19.SANDIGRAVEL PACK f n licable
•. - o.i:.• gMtpLAC£bff.Nf M1EI'HOD
DAquifer'StomgeandReeI ❑Salinity Barrier ileoat TO MurERrAr.
Mquifeacsf ' % . CIStormwaterDrainage h' ( lL a yr
OExperimental Technology OSubsidence Control n' It
AGeotheimal•(Cldsodioop) ❑Tracer 20:DRILLING LOG attach edd;tloael!♦bats R access
am
r - FROM TO DESCRII'1TOMT rotor 6uda wllrwck a eta
OGeol rermal: 'eatia Cooling•Retura E30ther(plain under#21 Remarks R ft.
4.Date WeII(s Rompleted: •Well lD#
So.WeU:Locatil in-
ft. n
Facility.Owner FacilityIDM(ifapplicable) L
-7!1C"n t�s�, Coldnt �I, �' Sllr 11•�r ft. IL ADD
_
f,
physical Address,'City,and-Zip
21.REMARKS ;.,., • �-_.,.,.�, _�, , _
Parul Identification No.(PDO
• 5b.Latitude aqd longith to degrees/inlnutes/seconds or decimal degrees:
(if-will field;one 1at%loug Is s�s®cient) 22.Ce co on:
j Signat=ofCclood WeltContractor Date
6,:1s(ate)theWcll(s): fflVe`rmanent -or. OTemporary
` r BysigninglUrjorm,1herebyeerltry that ShOVI II(s)was(were)eonaaaetedinaccordanceWrl,
7,is this s repair to an exlating well:; OYes or &-o 15A NGC 02C.0100 or 15A NGIC 02C.0200 Well Cwuhucdan Standards and drat a copy
90k is a repair,JIB out A-nown xA.ctipsnirction Wormallon and explain the nature ojthe ojr/r[r record has been provided to the well owner.
repair under gal l emarJtssection oron-the back afrhlsjtrrm. 23.She diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.Fbr.•deupr6hdDPT dr-..'Cto"sed-Loop Geothermal Wells having the same (add'Sea Ovetr in Remarks Hox}.Yon ntay also attach additional pages ifnecessmy
ctSnstm'ctibn,oily i GW 1 isneeded. Indicate TOTALNUMBER of wells
drilled: ` 24.sUBmrffAL nvsT ucrtoNI'ls
9.T tal tyell,:dgpttielow land surface: v (it) Submit this GW 1 within 30 days of well completion per the fallowlag:
Forrr�uLdpleS�e,Jgf ,lldeppth fdgeren!(example.3©200'and2Q1001 ,
•' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static waterlevel:below top of casing: " (fh) informadoa Processing Unit,1617 MSC,Raleigh,NC 27699-1617
0-ter ievel!s'!d ova easing,ase"+�
124b.For Infection Wells:Copy to DWI;,Underground Iajeclibn Control(IUC)
11.Borehole diameter: {in,) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well coast I cdon method:- iM V 1� (ZOTdC 24Q For Water Supp1j and O en Lbo Geothermal Return Wells:Copy to the
auger,rotary icable,direct pusb,eto.) county environmental ea epartment o the county where nos ed
FOR;WATERjSUPPLY WELLS ONLY: 24d.Far Water Wells trodudn over 100,00 GPD:Copy to DWR.CCPCUA,
A ;�. Permit Vwn,1611 MSC,Ruler C 27699-1 1 t
13a.Yield(gpm)_. 01 ` Method of test: A
l ti 13b.DlslnfectIoo type: C.rilOf'(dUl Amount: Z'
S
Form OW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 6.6-2019