GW1--03857_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information•
Gam), r ( Gc.!J 'L - 1'4.VIrATER.ZONES
FROM TO DESCRIPTION
Well Contractor Nam%
ft.
NC Well PantractorCertification Number 16 1f)TER.CA311!IG.for•in ti:tased ivtW OR INER'if8 cable
I / 7 FROM TO DIAMETER TffiC[INPSS MATERIAL
LLBm I/ d'ALLI o,�c, ' f<. Gf r�,l or �• SDXal I PU c
Company Name !., ��7•^ 16.•I$rNE ':CASING 0 • 'T G- 'edtherm'el'.d osa 4nnnl
2.Well Construction Permlt#: '-) 10, .-Z FROM I TO DIAMETER I TWL NESS MATERIAL
List all applicable well construction permits(I.e.UlC,County,State,Variance,etc.)
ft. ft. �•
ft. ft. �
3.Well Use(check well use):
1•..SC EN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E)Murlicipai/Pablic ft. ft. hL
Geothermal(Heating/Cooling Supply) ffKsidential Water Supply(single) fr ft. in. I
Industrial/Commercial Residential Water Supply(Shared) iS..GRIn
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri scion
Non-Water Supply Well: D ft. 4 j D
Monitoring ORecovery fr. ft
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation . 19.SA"MIXAVEL PA Kn if:a li a le
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ;,�•, 13Stormwater Drainage
ft %
!�!,> it. ft.
Experimental Technology i3r , Subsidence Control
Geothermal(Closed Loop) Tracer 20,0)RILLINGLOGIattseh dditibnalsheet:lf necessa
FROM TO I DESCRIPTION color,bardness soWnck aim etc.
Geothermal(Heating/Cooling Return) i. Other(explain under#21 Remarks ft. ft• '
4.Date Well(s)Completed: �r=3 arced D�tJ rt lrr-f"L
ft. ft. . i •. 'Poe
5s.Well Location: ft. '^y'— �:�.• .~e
ft.
I -ALL
11 ft. ft. N L I
Facility/Owner Name Facility ID4(if applicable)
— ft.
l a ICJ P [L r U _ u
Physical Address,City,and Zip ft, ft, 6WQ;50G
21.RE ARK$
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/second or decimal degrees: '
(if wolf field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or•Temporary
Signatwe ofCertified Well Contractor Date
By signing this form,!hereby certo that the well(s)was(were)constructed in accordance
7.Is this s repair to an existing well: []Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 well Construction Standards and that a
Ifihis Is a repair,fill out known well construction information a explain the nature oflhe copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-I:oop;Geothcrmal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.'InIdicate,TOTALNUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: — SUR f.)NSTRUCTIONS
9.Total well depth below land surface:•,_ :�2'Ll S (ft-) 24a.' For All Wells: Submit this form within 30 days of completion of well
Par multiple wells list all depths(fdorarent(exarpple-3 200"and 2t@1001 construction to the following:
10.Static water level below top of casing; r}3 2-0 (ft-) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:° (in•) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�/- above,also submit one copy of this focus within 30 days of completion of well
12.Well construction method. �L 14 V construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc,)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test; 24c.For Water SuDDIv&Injection Wells'. In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I o 1^/d Amount: L�(j• .S 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 Environmental Quality-Division of Water Resources