GW1--04048_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:---7;/7 4 v+ J-4r 7 k e )1 J/Ci/`/
FROMATER•ZOONES DESCRIPTION
Well Contractor Name
ft. ft. D
ft. ft. �I
Gso 1) r
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells R(if ap licable)
�J�j1�G19/J ro S: %C t . FROM TO DIAMETER THICKNESS MATERIAL
Company Name j//� ft. ft. // // in. 3 f/j yG
15.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: /2 5'7 7`{ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: T7.SCREEN_.
FROM TO DIAMETER • SLOT SIZE THICKNESS MATERIAL
0Agricultural 0Municipal/Public --0'- t: ft. in,
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
0Industrial/Commercial 0 Residential Water Supply(shared) aB GROUT ._
nirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t. t ^+l f
Monitoring Recover)/ 0 f f .'t1�- -Zy.19v Y/ /2
/bid
ft. ft.
Injection Well: ' 7..,..„.„
ft. ft.
Aquifer Recharge ]Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
B Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
0Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) I i Tracer .20.DRILLING LOG(attach additional sheets if necessary)
Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Q Geothermal(Heating/Cooling Return)
0 ft. a ft t/n;f L
4.Date Well(s)Completed: ,S '-/./— ell ID# ft. 34 C. A
5a.Well Location: 2 `fit. G a a ft. �/� !`
'�( �J P /��q r7 IIGf,I`�
OJ 6-✓en 4,sa�G y i e it 49•C P- J v ! ' �, 6 ci ft. •1�4 ft. icp.1 c:A.
Facility/Owner Name - Facility ID#(if applicable) ft. ft.
J/ (� /"C 6"� e',.ii Pi 1/Y+-r J / 427P1 eI E/Iti A / .ft ft t^^,/•' •r.. a,
Physical Address,Cit and Zip L ' } i �'J""'�
��QJP(j�£S ft ft t.,� l� i is '.. P
/LITe r o /93 00a$'6 37e"o `21.REMARKS . . . O,
dUlq 2 2 2023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ti' 1g+1?cr•rg��,_.
(if well field,one lat/longFis sufficient) 22.Certification: C •
,d Ly
3 1 �h t//7<Src /r rAs,i c/r1 '( W /f
6-Is(are)the well(s) mancnt or Ili Temporary Si a •ofCe ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 1K with ISA NCAC 02C.0100 or ISA NCAC 02C.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 of this 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V.�` v (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100')
construction to the following;
10.Static water level below top of casing:
Ifwater level is above casing,use"+' (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 102 (in.) ,, - 24b.For Injection Wells: In addition to sending the form to the address in 24a
/`J
12.Well construction method: �"a¢ above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) / construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) >1Method of test: /4 r):f ' 24c.For Water Supply&Injection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: !�/f r:A G Amount: ....5y e,Z , completion of well construction to the county health department of the county
where constructed.
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016