GW1-2023-02749_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD(GW-1) r Internal Use Only:
1.Well Contractor Information:
Tonf n z1-A14v*eA J;V1
Well Contractor Name FROM ft TO I DESCRIPTION
a f A- t. It. I -zv o 1
ft- :2161
NC Well Contractor Certification Number
,-15.OUTER'C.ASING(for iEiilfi:iitsed. lb)*ORMERI(if.iitbuiAble)';!'*..,?i'...!i.-..- -Z
FROM I TO DIAMETER THICKNESS I MATERIAL
Company Name yXe ft & , 1- .3.;?5- l )1"
41G INNER CASING'OR::::
2.Well Construction Permit#: IR ; 3' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(Ze.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: jIMSCREEN.'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
3Agricultural OM;rucipaMblic 0 ft. ft.
JGeothermal(Heating/Cooling Supply) E3 esid,.Iial Water Supply(single) ft. ft. in.
lIndustrial/Commercial []Residential Water Supply(shared)
.7
'lIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
DMonitoring [3Recovery ft. ft.
Injection Well:
ft. ft.
—JAquifer Recharge [3Groundwater Remediation OF
,219.SAND/GRAVE L'PAC (ifii66U6ible b'.",*.---.'ya-..:;f�."."'..*-,"..Iil.ul:
DAquifer Storage and Recovery E]Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test Ottormwater Drainage ft. ft.
3;Experimental Technology []Subsidence Control ft. ft.
-IGeothermaI(Closed Loop) []Tracer
t3Geothermal(Heating(Cooling Return) n Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,bards soiVrock bye,gr2in size,etc.)
6P % z ft. 4W , /
4.Date Well(s)Completed: Well]DO 16 ft J 3 ft' I
5a.Well Location: / 3 ft. XPX--"- A &e-R
13
Facility/Owner Name Facility ID9(if applicable) ft. ft.. V
C2 4 2, ;<ri e
ft.
Physical Address,City,and Zip rL 4
.21;
County Petrel Identification No.(PIN) APR I M2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) n C, x;3 z ww,;r.
22.Certification:
X Q c/Y 1-13�' N �7 -I, C M -95W-5 3
6.Is(are)the well(s)�ermanent or []Temporary Siql of Certified W&T Contractor Date
By signing this form,I heriby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [:)Yes or 01C. with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeADPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —00 24a. For All Wells Submit this form within 30 days of completion of well
For multiple weirs list all depths Ydifferent(example-3@200'and 2@1005 construction to the following:
42 10.Static water level below top of casing: 3 (N Divisioi of Water Resources,Information Processing Unit,
If water level Is above casing,use 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:, (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy-s�f this form within 30 days of-couipletiopRfyell
12.Well construction method: s-o idt—I I const(uction''t—o;ihe 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 2709-1636
13a.Yield(gpm) 3 .6 — Method of test: 24c.For Water Supylv&Iniection Wells: In addition to sending the form to
6J/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount. 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