GW1--03727_Well Construction - GW1_20230602

Print Form
I
WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
�-Weu Conh�actor information; - -
(,^
1'4:•::11 R.7l1NE
Contractor
� I G�-: G`•' FROM TO DESCRIPTION
ft. ft
Well Contractor Name
g, ft.
NC Wall Co clot Ceacatiou Numbor �_ FROM
'IJ 1t•C TO' lNG'.far•in D 'rAhiETEReIIe O $a cMAITERIAL
S ,{
6.'INNE •:CASH Itarosel'•6 IC too
Company Name !n^ D q •7 9 mom TO DIAME ER Y [QiE89 MATERIAL
J� "j of ay ft. ft. In.
2,Well Construction Permit#: a fAC,County,State,Variance,etc.)List all applicable well consirucdOr perrnlls p. • ft. ft.
3.WeU Use(check well use): 1..,g'. EN
FROM TO DIAMETER SLOT312Ii TIHCIQJESS MATERIAL
Water Supply Well: ft.
Agricultural [)Municipal/Piiblic
Water Supply(single) ft, ft-
Geothermal(HeatinglCooling Supply) 4,sldential
Residential Water Supply(shared) 18,.G .UT EMpLACEMENT METHOD&AM UNT
Industr!aUCommcroial FROM TO MATS'
Irrl atIon b tt. ft. L' Olt
NOD-Water Supply Well: H ft.
Monitoring Recovery
Et. it.
Injection Well:
Aquifer Recharge [JGroundwaterRomedlation 19,SANII1GIIAVE1+FA. K If:a II a la EMPLACEMENT METHOD
a FROM TO MATERIAL
Aquifer Storage and Recovery: I..`t �Salunity Battler rt. ft.
Aquifer Test : '�.�\� �StormwaterDrainage ft.
••' S Control
ft,
Experimental Technology ubsidence 20,.1} LIN OG• `tech' 'il tihn .sbeat:if•naeesea she etc
Geothermal(Closed Loop) [DTracer FROM TO DESCRIPTION(color htudaess roWroek
Geothermal Heatin Coolin RetU n Other("Plain under#21 Remarks D ft. ft.
4.Date Well(s)Completed: Well ID# ft
5a.well Location., ft. fr•
��-1 ( �,� P r ft. h. �v ' 023
Facility/Ownor Name FaoilIty U)!F(if eppUcablo)
fr
ft.
Physical A ess,� d Ill - 21.RE ARKS
parceI identification No.(F,IN)
County
5b.Latitude and longitude In degrees/minutes/secont]F or decimal degrees: 22.Certification:
(if wall field,ose latiloog is sufficient) r
Signature of Certified WeU Contractor
' Date
6.Is(are)the wells) rmanent or [3Temporary By signing this form,1 hereby certify(hat the well( was(were)constructed in accordance
1 (�� with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siandardr and(her a
7.Is this a in
to an existing well: fJYes or hc�'r'O copy ojlhis record has been provided to the well owner•
(f Ihls Is a repair,fill out known well construction 1pformatlon and explain the nature oj<he 23.Site diagram or additional well details:
•rdpalr under 921 remarks section or oh the back ojthis jornt.
You may use the back of this page to provide additional well site details or we
ll
additional pages if necessary.
8.For Geogrobe/DFT or Closed ,.4"p Geothermal Wells having the same construction details. You may also attach
construction,only 1 ow-1 ia needed.'Indicata TOTAL NUNIDBR of walls �.,nwu,•r�r•er mrgTRiTCTIONS
ce: (fG) 24a:For�uso Submit this form within 30 days of completion of well
9.Total well depth below land surfa
For multiple wells list all depths(f dUferenl(example-3@200"and 2Q100� construction to the following:
Division of Water Resources,information
5]617 nit,
Ill static water level below top of casing: 1617 Man Service Center,Raleigh,NC 27699
Ijwaldr level is above caring use"+"
(�) in 24B
24b.For Infectio W n ous_: oat addition to sgcompletion the form to f s of well
11.Borehole diameter: above,also submit one copy of within 30 days o
r'a` construction to the following:
(i Well construction method: construction
auger,rotary,cable,d'aaot push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
[13b,
R WATER SUPPLY WELLS ONLY: t tc
L�,/ }^ 24e.For�:' pDP I v'Infectlon WeUa: of sending
30edays of
,Yield(gpm) / Method of test: the addresses) above, also_submit one copy
e Amount: counpledon of well construction to the county health department of the count)
Disinfection type: C11. D where constuvcted,
Revised 2-22-201
North Carolina Department ofSnvirowwr l Quality-Division of water Resources
Form OW-1