GW1--04573_Well Construction - GW1_20230714

r v a.RsL a..VL•10 111Ue...11V 1‘tUL .UIUJ its W-11 For Internal Use Only:
I.Well Contractor Information:
ry
- "`")) `C -"f 14.WATER'ZONES. ^ .- _. .
Well Contractor Name FROM TO DESCRIPTION
( Z3 A- AD ft. /( ft. ,9� 5/
NC Well Contractor CeriificationNumber ��bft. 3g� R, lcr,��
/ r .15.OUTER CASING(for inulu-cased_meIs)OR LINER(if 4•licabte)..
Y - i 414 4_ t Jl I fL�r o#/ FROM TO DIAMETER
DIAMETER _THICKNESS ,RATERIAL
Company Name 1/�1C V` f r(/V/ ilVf dr 30 fl, in. l�L h Y6 6.
l �P /0 7 p / .16.INNER CASING OR TUBING(geothermal. ..... ._-_
2 Well Construction Permit#:/Y U FROM TO DIAMETER TIIICKNFSS MATERIAL
List all applicable well construction permits(l.c.VIC Corn!}: tate.Variance.etc.) R. ft. in.
3.Well Use(check well use): R. R. rn
Water Supply Well: -FRO I E TO DIAMETER SLOT ZE TrirCIMESS MATERIAL
Agricultural DMunicipaVPublic ?/�( fL 3 61, 7 , In. 4 — V° % q, , �i -
Geothermal(Heating/Cooling Supply) ,d:i Residential Water Supply(single) ,�W ft. l/"" IL !f in. c9
Industrial/Commercial liiil Residential Water Supply(shared) •
18.GROUT _._ ._
Irrigation FROM TO M;A�TERIIAL�� E11rLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. fl. % .44. rJ "a/ NV-jI/A.�-
.-. - Monitoring -- Rccovc —- =
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19:SAND/GRAV.E4PelCK(if applirable)
Aquifer Storage and Recovery 0Salinity Barrier FROJl TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 30f' ,3fo ft / / L.(,efa-i/�
Experimental Technology DSubsidencc Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG:(attach additional sheets,if.hecessary) ..... '
Geothermal(Heating/Cooling Return) Other(explain under 1121 Remarks) FROM TO DESCRIPTION(color.hardness,salVrock ypc gain size,etc.)
ft. ft.
4.Date Well(s)Completed:�_ Z3 03 Well ID# ft. R.
5 Well Location:
ft. ft. '
?,1 o1/A Cyr _ .. Zk ft. fl. " X
FacicrName . - Facili IDti ifs licable ft.
r 7ni CAM A ft., f. .'u_.:, _. .:..a wr _w 1).�
Y� w W
Physics ddress, and Zip
R. ft.
/ t C6 21:REMARKS. .. JUL - 2023 ...
County Parcel Identification No.(PIN) :
r- -, '''-^•-.7. �•'.'.1 t....n'
h,,.,"
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one fat/long is sufficient) 22.Certifmcatio
t5� 37'1/ y N 72 A ' �
`zG ' W 1:
6.Is(are)the well(s) Permanent or EITemporar} S. r re o c ,e. ell atractar me `
TTT��� - I i7y.,:going MS fona,I hereby cert+jy that,the%Wks)was(were)constructed In accordance
7.1s this a repair to an existing well: ©Yes or No :idi 1S.!N 4C t)2C.0100 or 1JA NCdC 02C.0200 Well Construction Standards and that a
If this.is a repair.fi11 out/roust well conservation b jorn,atior an lain the nature of the ropy of this record has been provided to the well owner.
repair under till remarks section or on the back of this farm. ,
23.Site diagram or additional well details:
S.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,only 1 GW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
•9.Total well depth below land surface: j �� VO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ample-3@200'aucl2@100) construction to the following: '
10.Static water level below top of casing: % (ft.) Division of Water Res'otirces,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
1I.Borehole diameter: 7 3/y (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Al/ti Li l i construction to the following:
(Le.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
r j '
13a.Yield(gpm) r) Method of test: )Gt 24a For Water Supply&Infection Wells: In addition to sending the form to
f/ L / the address(es) above, also submit one copy of this form within 30 days of
17
13b.Disinfection type: T 14L Amount: (Q 02-- ' completion of well construction to;the county health department of the county
where constructed,
I
1
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016