GW1--03942_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:�
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1:4.._WATER NE I
FROM TO DESCRD TION
Well Contractor Nama fr. ft.
ft .
NC Well Contractor Cartificatfilon Number ���t 15 OY]FER C 'SING.for•in :cased wbtis Olt INER'ifa cable
�•�I I��i/i—/v�� C � FROM TO DL\METER THICtflVFSS MATERIAL
a �5 a, ric r ' ft. tt �, z5'° 5 D Rz1 ✓G
CompanyNama ii I6.' C II9GORTr1 G 'edthermal'•egsed-Leo
2.Well ConstructioD Permit M��1 AJ-2 ~ d 02. FROM TO ft, DUMETER THICKNESS MATERIAL
List all applicable well construction permlis(l.e.WC,County,State,Variance,eta) ft. �
-- +---
ft. ft. �
3.Well Use(check well use):
17.SC EN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallArblic ft. ft. IP'
Geothermal(Heating/Cooling Supply) Wpidential.Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18..i It .UT
FROM TO 11fA EMPLACEMENT MET�OD&,MOUNT
Irri ation
Non-Water Supply Well: rt. o'i-U fr' h r> rt 1 13 b a. s — I'e_
Monitoring Recovery fr. ft.
Injection Well: [t. ft.
Aquifer Recharge Groundwater Remediation .19.SA1VDlGRAVEL FACIE.Non licable.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�.`. ft. ft.
Aquifer Test 3StorrnwaterDrainage
Experimental Technology Via{ [)Subsidence Control ft. ft. e
Geothermal(Closed Loop) OTracer 20._iff IN LOG. Its, H tibnal.sheets:lf necessa.
FROM TO DESCRIPTION color,hardness soWrock s etc.
Geothermal Heating/Cooling Return) / Other(explain under#21 Remarks ��-q fr. �C y-
4.Date Weil(s)Completed: ,`t!�`�+ Well ID# (} ft. J JY fr. Q-
ft. ft.
Se.Well Location:
9� e✓1 ),L I— Yll l E1r0 S fL ft. s' •c: e.
Facility/Owner Name Facility JD#(if applicable)
��!o �m�� ism- �r, • o en. � � fL fr. JUti 1 2 2023
fr. ft.
Physical Address,City,end Zip
Rik
s�a_t�s
21.REMARK In
;r �
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
y l0 9 N J, g�35�� W /�.0
�� •�l J3
6.ls(are)the well(s)m ermanent or OTemporary. ro SignatuofCerHfledWollConoraator Date
By signing this form,I hereby certify that the wells)was(ware)constructed to accordance
7.Is Ibis a repair to an misting well: [3Yes or [DNo with 1SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
•rdpair under#21 remarks section or on the back ofthls 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 details or well
'
construction details. You may also attach additional pages if necessary.
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: _,_� _ SUBMIAMaRWRUCTION$
9.Total well depth below land surface: h o 1 (ft-) 24a: Eor All Wells: Submit this form within 30 days of completion of well
For multipla wells list all depths Ifdocrent&;tatitple-3@20i0"and 2@1007 construction to the following:
10.Static water level below top of cashlg. !0 (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: w (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
s above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / Y construction to the following:
(i.e.auger,rotary,cable,direct pushy etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) b Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
f, ) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C'`l rl�� Amount: 02 G[L 5 completion of well construction to the county health department of the county
where constructed
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-2016
Famr OW-1
North Carolina Department of Environmental Quality-Division of Water Resouices Revised 2-22
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