GW1--03657_Well Construction - GW1_20230526

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I Mint Form
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Dtractor Inf rma n:
1J all) tLwp 14'VPAT R.ZQNE
N �pM Tp DESCRIPTION
Well Contractor Name ft• 1t' f
cable
NC Wall Co tractor Certification N bar 15, UltE1t C' far in leased wells Olt INER'if a
Sil FROM TO DIAMETER THICf0VPS3 MATEIUAI.
Company Name C ' IIVG OR edtharmal'•d SIC[0YE9 c too
���e FROM TO DLA111ETER 1 9 MATERIAL
2.Well Construction Permit#: ft, ft. In.
List all applicable[veil construction permits 0.e.fllC,County,state,variance,eta) in.
ft. ft.
3.Well Use(check well use): 11. K.
EmC
ly Well: FROM TO DIAMETER SLOT SIZE THICEOVESS MATERIAL
M cipal/Public ft.
al al(Heating/Cooling Supply) q.3 ential Water Supply(single) tf,ommercial Residential Water Supply(shared) 18.. 2t UT EMPLACEMENT METHOD&AMO T
FROM TOMATERAAI Supply Well:
•Monitoring
Recovery ft, ft.
Injection Well: tR ft.
:.)Aquifer Recharge ®Groundwater Remedistion .19,S G If a II a le
EMPLACEMENT METifOD
Aquifer Storage and Recovery ti E)Salinity Barrier FROM ft. TO .ft. TE
Aquifer Test \ E)StormwaterDrainage
.N•' Subsidence Control tt. ft.
Experimental Technology y
Geothermal(Closed Loop) Tracer 20.'l) LIN OG. ttacLem tlba sheet:if necesea
FROM TO DESCRIPTION color hardness soWrock size eta
Geothermal Heating/Cooling Return Other ex lain under#21 Remarks ft. ft, Y
4.Date Well(s)Completed: Well W# (/p fA t7�fA V Gt-Ki
ft. ft.
So.Well Location: ft.
Facility/Owner Name Facility W#(ifopplicable)
_ �q l.arcra l' ft. ft• MAY 6
f i, �.
Physical Address,City,and Zip 21 REMARKS - sS tEi1 ' r:sGwtt�r^�' n',4
County Parcel Identification No,(PIN)
5b.Latitude and longitude In degrees/minutes/seconts or decimal degrees: 22,Certification:
(if wall field,one lat/long Is sufficient)
�J.��� W
Signature of ertified Well Contracto Data
6.Is(are)the well(s) ermanent or Temporary
0Y signing ihis form,!hereby certUy that the weli(sJ runs{lusts)constructed in accordance
with!SA NCAC 02C.0i00 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Yes or �NO
copy ojthis record has been provided to the well owner.
(fthla is a repair,Jill out known well construction irtformation and explain the nature ojthe
rApair under N21 remarkr section or on the back ojihis form. 23.Site diagram or additional well detalls:
You may use the back of this page to provide additional well site details or well
8.For Geoprobo/DPT or Closed-Loop;Geoth'crmal Wells having the same construction details. You may also attach additional pages if necessary,
construction,only I GW-I is needed,'1 ndicaie TOTAL NUMBBR of wells tunTi Ai,INS i RUCTIONS
drilled:
9.Total well depth below land surface: b_ (ft-) 24a; )For All Wells: Submit this form within 30 days of completion of well
For mulilpfa weirs list all depths Ifd(jJ-erenl(example-3(�00"and 2 l00
9 construction to the following:
10.Static water level,below top of casing: 5O (fL) Division of Water Resources,Information Processing Unit,
ljwater level!s above casing,use„+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diemethr: 6_ (in•) 24b.For Isle jjgn Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction methods �© r coilruction to the following:
(i.e,sugar,rotary,cable,direct push,etc.) Division of Water Resources,;Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
` 24c,For Water a"""r"R'Inlccuion Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the jaddress(es) above, also submit ono copy of this form within 30 days of
t completion of well construction io the county health department of the county
13b.Disinfection type: Y Amount: c S where constructed.
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North Carolina pepartment ofSnvlrcarneatal Quality-Division of Water Resources
Revised 2-22.2016
Form OW-I