GW1-2023-02805_Well Construction - GW1_20230417

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Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: „
1.Well Co tractor informatl
/'r n "
�J a 1'4:'VPAT ZONES
PROM TO DESCRD TION
Well Contractor Narat ft. ft.
Lf —� ft. ft.
NC Well Contra•ctorCodification Number r I'$•• R•C ' .G.for••m 'tosed wblra 0R 1NER'lfn cable
J FROM I TO DIAMETER T9ICIUMS MATERWL
' ft. ft. !!' Al I FJVC-
company Name •6.' :C ' IIAG ' 'T r bdtimecm'el:d aaxd-loo
2.Well CoDstrucdon Permit#: ! / FROM I TO I DIAMETER I THICKNESS MATERIAL
Lisr all applicable well construction permits(I.e.UDC,County,State,Variance,etc.)
ft, ft. �-
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER I sLOTSIZE I -IML; FSs MATERLIL
.Agricultural C)MunicipaWablic ft. Ift.
Geothermal(Heating/Cooling Supply) wqpidential Water Supply(single) h, ft. In
Industrial/Commercial C)Residential Water Supply(shared) is.•G '•.UT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO T
Non-Water Supply Well: ft.
e1L1
14 3"s 4LLL�
Monitoring Recovery ft. ft.
Irjection Well: ft. ft,
Aquifer Recharge Groundwater Remedlation 19.9APtt1lG 'YEL FA iC t a ii aUte
Aquifer Storage and Recovery 1, , OSolinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 1: '`� 3Stormwater Drainage ft. fa
Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Traeer 20.,])RMLrNrOG. ttactr il tibn sheet:Ifaet saes
FROM TO DESCRIPTION color hardness eoWroek elzs etc
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks)Dft. ft.
,L tX-
4.Date Well(s)Completed: �r�-t� �1 Well ID# ft' �n L-
ft.. ft. _ -
5s.Weep]_Location-,
�a YY1 P,5 fa ft.
Facility/Owner Name Facility lD#(lfapplicable) APR 1 '7 '1
ft. ft.
Physica�Adrcss,Ci�,and Zip ft N,
21.REMARKS
5
County Parcel ldantificatiou No,(PEN) -
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(1f W01180Id,OaOIeUloag Is sufficient) 22.Certification; Azw(- 3 0
, er Signature of Certified Well Contractor Date
6.Isis re)the well(s) maneat or.OTemporary -
e�,,,ceee By signing this form,1 hereby cert(fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yea or No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
(f this is a repair,Jill our known well eowhwotlon iyJormorlon a explain the nature of the copy of this record has been provided to the well owner. .
--repair under#11 remarkr section or on the back ofthls 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=Ygop;Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 OW-1 is needed.'Indicate.TOTAL NUMBER of wells
drilled: 2 SUB L INSTRUCTIONS
9,Total well depth below land surface:_ (ft•) 24a: FEo•All Wells: Submit this form within 30 days of completion of well
pop multiple wells list all depths(fdpren((et:attrple.3 200"and/20100) construction to the following:
10.Static water level below top of casing; (R•) Division of Water Resources,Information Processing Unit,
/fwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamLter: (in.) 24b.For Inloctfon Wells: In addition to sending the form to the address in 24a
above,also submit one copy pf this form within 30 days of completion of well
12.Well construction method: 0 / t — construction to the following:
(i.e.auger,rotary,cable,direct push,etcJ
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (1 D Method of test: Q! N 24e.For Water Sunaly&Iniecdoa Walla: In addition to sending the form to
rr the adaress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C n D Y Amount: G t[ completion of well construction to the county health department of the county
where constructed.
Revised 2-22.2016
Form OW-1 North Caroline Department of Enviroarnental Quality-Division of Water Resources