GW1--03725_Well Construction - GW1_20230602

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well contractor Information: i
�CrrY 'l 1 pot - FRV(tAT R. NES � '
yv � FROM TO DESCRn'T10N
Well Contractor Nama fr. ft.
ft. ft.
NC Well CoatractorCartilicetioo Number 1$,• 11111;R•C'SiT!TG.Car•in lease wells OIZ INER'lta cable
FROM TO DIAMETER THICEOfESs TERLAL.
e l I CA Yk m CI. fr, 0 fL S in. 2( 1�C
Company erne 6.' C ' I19G UR edtfiarmrsl'•d ale d-too
2.Well Construction Permit#: , " �3 _OI� `� FROM To DIAMETER THICKMS MATERIAL
List all applicable well construction permits(l.e.WC,County,Wale,Variance,eta.)
ft. it. �
ft. t6 in.
3.Well Use(check well use):
1..S'• N
Water Supply Well: FROM To DLIMETER SLOTSIZE TLDC[OVESS MATERIAL
.Agricultural ®Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) [3Rq?IdentI81 Water Supply(single) fr, ft. h•
Industrial/Commerciai Residential Water Supply(shared) 18..ialt•UT
FROM TO TERUL EMPLL.IACEMENT METHOD&AMOUNT `
Irri ation fr, 2(�' ft. 0 r f f U Ci !o D LL.Y dtl
Non-Water Supply Well:
Monitoring Recovery fr. ft.
Infection Well: ft. ft.
AquiferRecharge ®GroundwaterRemedlation 19.8A14D/G 'YELPA. IE,1Ca li a le
Aquifer Storage and Recovery oSolinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
A. ft. ft.
Aquifer Test ; A•, [3Stormwater Drainage
Experimental Technology ;+Z(' [3Subsidence Control tL ft. .
Geothermal(Closed Loop) Tracer 20.'D L11V LOG. ttadlr 'a. tiDnal:aheet:iCnecesea
FROM TO DESCREPTION color hardness soWroek typ size eta
Geothermal(HeatinglCooling Return Other(explain under#21 Remarks O it
4.Date Well(s)Completed:5= Well W# It. v Jfr'
ft.
ft.
5a..jW ft.
]Well Location: (� _
PA I�/PJ✓S_
rt. ft.
Facility/OwnerNama ) /1 FaoilltylDN(if applicable)
� l Orht�V a� ft, ft. JL�J �l �� 702�
CU Auc,
ft. ft•
Ph jical fAdddress.City and Zip
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I t/t Yl C'Jtr Cl 2I,REM-AM
County Pascal Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconts or decimal degrees:
(if well field,one Iatilong is sufficient) �i �y 22.Certincation:
3 5, 390 3 d o N O �, 56 1555 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permauent or Temporary
By signing this form,I hereby cerl(/y that the well(j)was(were)constructed In accordance
7.[s this a repair to en existing well: [Dyes or j&o with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction standards and that a
If this Is a repair,Jill out known well construction iq formation and explain the nature of the copy of this record her been provided to the well owner.
repair under 021 remarks section or on the back ojthls form. 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 site devils or well
construction details. You may also attach additional pages if necessary
construction,only 1 GW-I is needed,"Indicate TOTAL NUMBBR of wells .
drilled: � StIBMITPA r•INSTRUCTIONS
9.Total well depth below land surface: �L­: (ft•) 24a: ,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdissrent(exarpple-3@200(0'"and 2@1001 construction to the following:
10.Static water level below top of casing";, 0 A) Division of Water Resources,Information Processing Unit,
If cosier level Is above caring,use' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diamdtbr: (in.) 24b.For Infection 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 method; A0 1 r v 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: I♦' 24c.FQr Water SuDDIv&Injection Wells: In addition to sending the form to
( n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: y 1 t Amount: e((I/ completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016
Form OW-1 North Carolina Department of Enviroamantal Quality-Division of Water Resources
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