GW1--03333_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
PrA dQ t'.4.'VI�ATER.7 TOL"ES
l/ FROM TO DESCReTION
Well Contractor Namc ft. ft.
(45 V s -,4• ft. ft.
NC Well Contractor CoAification Number (n_ 15rUk1T1FR CAs1TIG.ior•inW rea'9eed iveUs O}t LINER'i[a Iicable
ril/aM1 (',lVl l� `��, 10M fr• b TO 0 ft. D.Z JCR ln. TIII z l ms �C
Company am e I6,'INNE ':CASINGO&'Tc1IivG edttierm'el'elosad-loo
2.Well Construction Permit#: ,V ` o EOM TO D S MATERIAI
MtMn R TffiCKNES
List all applicable well construction perml/s Q.e.WC,County,Slate,Variance,etc.) fL �
+ft —
•
4—
ft. �•
3.Well Use(check well use):
17g&-P.R
S'G EN
'Water-Supply Well: TO DIAMETER sLOTsrzE THICKNESS MATERIAL
:.]Agricultural C)Muaicipal/Public ft.
Geothermal(Heating/Cooling Supply) J§Rgsidential Water Supply(single) ft, In.
Industriamommercial Residential Water Supply(shared) TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation �.0 ft.Non-Water Supply Well:Monitoring Recovery ftInjection Well: ft.
Aquifer Recharge [)Groundwater Remediation .19.SANDIG -. PACK,if;a lice'le
Aquifer Storage and Recovery 1 Salinity Barrier FROM A MATERIAL EMPLACEMENT METHOD
Aquifer Test ;, `•, [3Stormwater Drainage ft tt
Experimental Technology ?+r'i^ Subsidence Control ft, ft.
Geothermal(Closed Loop) OTracer 20.'DRILLIN LOG.attao'h dtliNbnal sheeta:ifnecessa
FROM TO DESCRIPTION color hardness soWrock size etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks d ft. so ft. Glaly
ft.
4.Date Well(s)Completed: 3_ Well m# OS «vt t
% ft.
5a.Well Location:
1_ Q ft. ft.
0 q trb e 1 �t! f ft
Facility/Ow r Name // Facility ID#(if applicabllee)
iG! (O SurMt'ni-f' Qr.J (7YUno�t/►GtN #('6o ft. NJAY y
rt. ft.Physical Address,City,and Zip ; F
/�J�/� 21.RE ARKS '
/e �/��INP/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.CerNffcation: AN
-Fl/. glI2,3 WSigns .Mert fW Well Contract Date
6.Is(are)the well(s)J@Permanent or [3Temporary.
BY signing this jorm,I hereby curio that the well(s)was(tivereJ constructed In accordance
7.!s this a repair to sa existing well: Yes or �No with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
copy ofthis record has been provided to the e!i owner.
ljthis Is a repair,fill out known well eonsimcdon Information and explain the nature of the
--repair under#21 remarks section or on the back of thlsform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-hoop;Geothermal Wells having the same You may use the back this page provide additional well site details or well
construction details. Youu may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'hrdicate TOTAL NUMBER of wells
drilled: —_ SUHMTrM)1NSTRUCPI M
9.Total well depth below land surface: 50 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdVerent(exarpple-3(200"and 20100') construction to the following:
10.Static water level below top of casing-, /00 YQ Division of Water Resources,Information Processing Unit,
If water level Is above casing use"+"G 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamgter: v (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Q above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /"la construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: /" r 24c.For Water Sunaly&Injection Wells: In addition to sending the form to
�f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 0fYt M Amount; ^ GV 's cotnpledon 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