GW1--03941_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.T11 contractors infoorrmation-,
7 � P'Ct 14:1(rAT R
Ol r / . NE3
PROM TO DESCRn'TTON
Well Contractor Name fr. ft.
Lr y L15 A• , ft.
NC,)well Contractor Cortifioation Number 15, .D lt•C' .G.Tarim Teased wells OIZ AVER's cable
L�►lnt S ,� qVIdV 1M• ft. 9 ft.TU D R In. C[W2 1 MATERIAL
Company erns n 16.•1 •:C ' I1VG +1t edtherm'al ti vied-loo 1 V
< jn/23 —O S Q�-� FROM TO DIAMETER TffiCKNEaa MATERIAL
2.Well Construction Permit#: Y V ft, ft. �
List all applicable well construction permits(1•e.UIC,County,Slate,f arlance,eta) In.ft, ft.
3.Well Use(check well use):
Water Supply Well: FROM To DIAMETER sLOTSIZE TtnctQ+Ess MATERIAL
Agricultural [31viunicipaMblic fL ft. in.
Geothermal(Heating/Cooling Supply) MIR@sidential water Supply(single) ft, ft. hL
IndustriallCommercial []Residential Water Supply(shared) Is..ial QUm
FROM TO MATERIAL EMPLACEMENT IFIETHOD&AMOUNT
In; slice G fr. 20 ft. Pz . I'3 'f3C1
Non-Water Supply Well:
Monitoring Recovery fr. tL
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19,sA1dG 'VEL FA. IC jaa 11 a le.
EMPLACEMENT M OD
Aquifer Storage and Recovery ` Salinity Barrier FROM ft. TO ft. MATERLAI
ETH
Aquifer Test �1; C)StormwaterDrainage
Experimental Technology !:+K(T [3Subsidence Control ft' fG
Geothermal(Closed Loop) Tracer 20.0) LiN LOG. tts&r 'a Hhn sheet:ifaeeesea
FROM TO DESCRIPTION color herdaeae eoWrock size eta
Geothermal Heatin Coolie Return) Other ex lain under#21 Remarks ft. �� ft. 1 a l
4.Date Well(s)Completed:5Vi9/' 3 Well ID# !r
ft. ft.
5a.Well Location:
ft. fr.
Faclity/OwnarNe ma FacilityID# ifsppIlcable)
- -- -- — - ' "
'EIS :7 p �y,32i fr. � JUN
Ph sical Ad ess,Ci ,and Zip
ZI.REMARKS
1 1�
County Parcel ldendfication No.(PIN)
5b.Latitude and longitude in degrees/minutes/secongs or decimal degrees:
(if woo field,one lat/iong is sufficiont) 22.Certification:
3-5. L�-N W
-` signatureof Certified we Contractor Data
6.Is(are)the well(s)i5Permanent or Temporary
By signing this formI hereby cer!(�y that the well(t)was(were)constructed In accordance
7.Is this a repair to an existing well. foYes or,jNo with ISA NCAC 02C.0100 or IJA NCAC 01C.0200 Well Construction Standards and that a
4rthtr!r a repair,Jill out brawn well construction lrlformatton and explain the nature of the copy of thls record has been provided to the well owner.
-repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop;Geoth'ormal Wells having the same You may use the back u attach this page t pa provide additional well site details or well
'16dieata TOTAL NUMBBR of wells
construction details. You may also additional pages if necessary,
construction,only 1 GW-1 is needed,
drilled; SURN ggpL09TRUCTIONS
9.Total well depth below land surface: �G'S (fL) 24a; j pr All Wells: Submit this form within 30 days of completion of well
For multiple wells Itst all depths(fdWerent Oxarlrple-3 aCZ00'•and 2Q1001 construction to the following;
10.Static water level below top of casing,'- 60 (fL) Division of Water Resources,Information Processing Unit,
If water level Is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole dlana&4: (in•) 24b.For Injection Wells: In addition to sending the form to the address in 24e
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Q construction to the following:
g.e,auger,rotary,cable;direct push,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) JV Method of test: A 1, 24c.FQr`dater Sunnly&Injection Welle: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C Amount: U' completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofBnvironmactal Quality-Division of Water Resources
Revised 2-22-2016