GW1-2023-02930_Well Construction - GW1_20230420

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor info�rati� - --
_ G 11r FROM TO DESCRIPTION
Well Contractor Namtl V ft. ft.
y595 A ft. ft.
NC Well Contractor Certification Number 15 b PE -CA '.for•ingitlitosed iveUs UIt iNER'tf a cable
��n� FROM TO Q DIAMETER TffiCIWPSS MATERIAL
— ft. C7? ft. rJ' In. 1
Company N o �1 16.'UVNE ':C B9D + 'T edtlierm'el*o osed-loo
2.Well Construction Permit#: /t 2 3% FROM To DIAMETER I�clavEas MATERIAL
ft. ft. Im
List all applicable well construction permits(Le,111C,County,State,Variance,etc.)
ft, ft. In.
3.Well Use(check well use):
1..5 EN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICIOMS MATERIAL.
Agricultural DMunicipaMblic ft• ft. In
Geothermal(Heating/Cooling Supply) J&qldontial Water Supply(single) ft, ft. In.
Industrial/Commercial [311esidential Water Supply(Shared) 19.19A"/G;
TIrri ation TO MATE__R/IIAL/ EMPLACEMENT METHOD&AMOUNT
ft 1 < Gl � '9Non-Water Supply Well:Monitoring Recovery- ft.Infection Well: ft.
Aquifer Recharge []Groundwater Remedlation IG 'VEL PA IL r..n It a le
Aquifer Storage and Recovery Salinity Barrier TO EMPLACEMENT METHOD
Aquifer Test • ';�1;: Storniwatcr Drainage . ft.Experimental Technology ,iF E)Subsidence Control . fGGeothermal(Closed Loop) OTracer IN OG. tta6lr fi tibn -heel:Sfnecesea0 DESCRIPTION color bardnem soWrock elu ate.
Geothemlal Heatin Coo11n Rotum Other ex lain under#21 RemarksD g, a4.Date Wells)Completed: Wil1� . t ft. ft.
So.Well Location: . ft.
a,VI J Q V ft. ft.
Facility/Owner Name U Facility ID#(if applicable)
�1& a ,
ft. ft.
Physical Address,City,and Zip
21.RE ,� .
r
County Parcel Identification No.(PIN)
- "sui•� ;^a tT`�: .J Ali}t
5b.Latitude and longitude In degrees/minutes/secon4s or decimal degrees:, '
(ifwall field,out lat/long is sufficient) 22.Certification:
Iz�W N
35 . L
Signs ofCortifled'Woll Contractor Date
6.Is(are)the well(s)OPermanent 'or•Temporary.
03'signing this form,!hereby cerl((y that the wells)ivas(rvere)constructed In accordance
7.is this a repair to so existing well: ®Yes or-ONo with ISA NCAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthta Is a repair,fill out brown well construction 1gformallon and explain the nature ajthe copy ojthls record has been provided to the well owner.
-repair under#21 remarks section or on the back ojthlsjorm. 23.Site diagram or additional weU details:
8.For Geogrobe/DPT or Closed-Loop;Geot TOTAL NUMBER of wellsh'crmal Wells having the same You may use 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 I GW-I is needed,I Indicate
drilled: _ ;_- suB AL INR7•ItUCTL
9.Total well depth below land surface: d`�7 (ft-) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths IjdWerent(example-3Q2001•and 2Qa 100� construction to the following:
10.Static water level below top of casljlg; L� (ft.) Division of Water Resources,Information Processing Unit,
Ijtvater level Is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diatneter: 24b.For Injection Wells: In addition to sending the form to the address in 24s
LL above, also submit one copy of this form within 30 days of completion of well
12.WeU construction method:, C) ,V -- construction to the following:
(i.e.auger,rotary,cable,direct push,ate.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3 a �I r 24c.For Water Suldl B W
�Iniectlon ells: In addition to sending the form to
13a,Yield(gpm) Method of test: the addresses) above, also Isubmit one copy of this form within 30 days of
13b,Disinfection type: YI t� Amount: S completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Caroline Department of Snvlronmtatal Quality Division of Water Resources Revised 2-22.2016