GW1--03445_Well Construction - GW1_20230516

I
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. i
1.Well Contracto Information: j
`4 Q C� �34.RATER ZONES r -
FROM TO DESCRIPTION
Well Contractor Nang l
5- 3_ 4 ft. 27, ft. l�y sq,,y
ft ft.
N l Contractor c :cation Numb 1 /1 1S.OUTER CASING(for mold-creed ivells)OR�LINER'Of an•llceble) _ • -
)� t,t� 771L/11112e( a FROMfar n. DIAMETER Min. 57 W 1;V
IEN
Company Name ✓ l�
// �16.INNER CASING OR TUBING(geothermal-closed-loop)..�
2.Well Construction Permit#: 5/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well warinnetion permits(i.e.UIC.County.State,Variance,eta) ft ft. In.
3.Weil Use(check well use): sG fr. to
Water Supply Well: FROM I TO DIAMETER SLOT THICKNESS �MenTEnrnr
Agricnitaral ❑Mucicipal/Poblic /Qa ft •go ft. y ra- i� la Ya /UG
/❑Zrteotitminal(Heating/Cooling Supply) ❑Residential Water Supply(single) f Q ft n, i in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •' -
-—---ohrigation— ----- - --0Wells>-100.000 OPD _ FROM _To ATERIAL/ EmPLA r/errnyOD&AMOUNT
Non-Water Supply Well: a R'_ f t�` s%rif#> ,02�/ /574,
❑Monitoring ❑Recovery R. ft.
Injection Well:
ft. R.
❑Aquifer Recharge ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(If applicable) .
❑Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENrMETIWD
❑Aquifer Test CStormwaterDrainage / / W��v ft' 7`ryZ‘-',AA /� - 9'AG.e/196wJ,z
❑Experimental Technology ❑Subsidence Control ft. ft. j'
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness.eoilimdc type,odeth e,etc)
o' ft rr.
4.Date Well(s)Completed: 5 /O V.., WaIIIDll ft R.
ft. ft.
Sa 1Velll Location: p hl �/(
Facility/OwnerName Facility ID (fapplcable) ft. ft.
ft. it .. MAY1 (� 1UZ3
' p74 ?' ex, vo/r- gyps. ..
P feat A dress,City,and Zip •
�]/(f .7'0 3 7 ft. ft. IrcY�_,•-,;;,,.n pi�ra..;�'-,3 I lrl
L.f] 1 11 !! ! `i 21.REAiARKS c,,,,c1-"'J
aunty Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
-
(if well field,one latlkng is sufficient) 22.Certifies§,n : //
3s°#Y'3' r N /22 D d7' 8" W I c,� ' t /r5
6.Is(are)the well(s):jkermanent or ❑Temporary s; of Certified Well onuaetor Dot
gain:thisfornq!hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an e:feting well: °Yes or ehNo A NOW 02C.0I00 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
rthtr ha repair,fill out brown well construction Information an lain the nature ofthe ofthis record has been provided to the well owner.
repair under ti2I remarlasection or on the hack of thIsforrn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
driller!: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9-61 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(different(example-3Qa 200'and 2@I00')
fin h' 24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: : , ( ) Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is obese raring,use+" .
ypp 141' S�i 11.Borehole diameter: li' (in.) - 24b.For Infection Wells:Copy to,DWR,Underground Injection'Control(IUC)
��r 111 Program, MSC,Raleigh,NC 27699-1636 -
-
I2.Well construction method: > �{Uro �r�1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the'
(i.e•auger,rolary,cable,d'nect Push,etc.) J county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells producing over 100,000 GPD;Copy to DWR,CCPCUA
1 y '',1 Permit Program,1611'MSC.Raleigh,NC 27699-1611
13a.Yield
(gpm)
MP / Method of test:ri i
1
13h.Disinfection type: grit" Amount: 0 Z
•
Form OW-r North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018