GW1--04742_Well Construction - GW1_20230724

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.., :r<.:. v o w -..; ,. x, . i iv u vxil i i;.1 . W=1) Y
�r< or'Intemal Use Only;
1.Wlee1CContractor Information:
. sgk(14/- 6 r,hdtdh rr4r 14rJVA1ER'zQ1vCS . ;• `
FROM TO DESCRIPTION
Wen Contractor Narita /
�` - /0 ft,. 6, ' 'i6i1 I15.a// .5/.>L.
ft, rL
N `cllConlmetoct'edrficationNumber . '15.;OUTERCASING.(for multi-cased welts)OR'LINEt (ifap livable)`•--' -
�/ jA ,n I/ / 1 ,^ FROM TO DIAMETER THICKNESS MATERIAL
(/t/PJ( /fit./ (�.
Company Name. //e/� 0 /�. ft ,/ in, S��T© r,v ,
_ ���////// its ' ' IAMM tTE iho"rm'THICKNESS.loop)
fitie57-
16-INNER,CASING.2.Well ConstrucdotiPertitlt# Q �'" �� 7 FROMTO- DIAMETER FSS. MATERIAL
List till'applirtihle'iirlicdtistruciionpermits'(I.e Uic:Count);State,Variance.etc.). ft. ft., In,.
3:Well Use(check,.well use): ft. ft., in. . .
Water Supply Well;
Ffi O 1 iti_o DIAMETER �/SLOT 17.E TIUCKN'ESS MATERIAL
Agricultural DMunicipa1/Public / R: it: .. In. ! �Zv �G�,�Gr �Gcotbermal(Hcating/Cooling Supply) • Residential Water Supply(single) ///// ft `✓ ft in
Industrial/Commercial Residential Water Supply(shared) Itt GROUT;" „
_ Irrigation FROM TO Is••ijTERIAL EMPLACE,11&NTJ;IETIIOD&AMOUNT
T on-Water.Supply Well:. - - (I. t J ft. f 2)/65
Monitoring f Recovery ft, ' ft, ���"` b
injection Well:. It. rt.
Aquifer Recharge .DGroundstater Remedialion
I9:SAND)GRAVEL.PACK Of-applicable) -''„"
Aquifer Storage and Recovery ,QSalinity Barrier FROM TO' - MATERi a EMPLACEMENT METHOD.
Aquifer Test DStormwater Drainage /)�ft. / ,e II. �i ,,,�//a' it f j v,a
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTrticcr 20..DRILGINGiLOG_tattrich additional'sheets if necessary)"
FROM 'TO DESCRIPTION(color,hardness,soitlrock type grain sire,eiW
Geothermal,(Heating/Coalu)g Return) (Other(explainAtnder:121Remarks) 3 3 "fl, ft; /7 ' (�
4.Date Wells Completed:.-! Kl 23 Well IDS ft. rt. 1 '°:!`:
, ft,
5a,Well Location: II 2 a 2023 _
(i/1 1 (t e rJJ/d ft. ft. . JUL- tr
Facility/Owner Name Facility IOU(if R n Infdrii" a�a Pr;Tc Ur
/1I'/(" , ;dii (d/a1Y�� itiv,ysical dress,C't and Zip
fL
pi.,. �� (o / 31:-REMARKS.,,.
County Parcel Identification No,(PIN) - --
5b.Latitude and longitude in.degrees/niinutes/seconds or decimal degrees;. -
Owell Geld,oneaatilong is sufficient) 2 erlitie: i n: •
-1 °3 7 t q t, N -�.,fib. ` i .6 r, . �� ..
JJ
17W,2 3
6.Is(are)the well(s) Permanent' ,o) ora Tem ry lure of Certified We I Contractor Oa c
. P
ty signing this Jrnn l herrbj rrtifv that the,nYl!(s)_n•as(acre)constructed-ire areordanee- - •
7.Is this a repair to an existing Well: DYes or No" 1". tritlr/SA iv C'IC Q2C 0100 o IS lWC.'r1G 02C.0300 Dell constructionstandards and drat a
If this is a repair„fill out Rnunrt'n'ell'consrnrcilon;infprnrufion and •.rJ{lui»the ofnc� copy:of this recwd has-been protided to tiw hell owner.
repair under Yell mantas section or on the Back of this form. -
23,.Site diagram or additional well details:
3.For Geoprobe/DPT.or Closed-Loop Geothermal Wells having the same You may use he back of.this page to provide additional well site derails Or well :`
constRiction,"only 1 OW-1 is needed.•Indicatc,TOTAL.NUMBER.ofIvells construction details. You may also:attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
-9.Total well depth below land surface: 1 gj UG® .(ft) 24a. For An Wills: Submit this"form within,30 days of completion of well
For multiplamlis list all dipilts Ifd rent(r ramplet3@200''and:Cu110U:) conatnlcuo)i,to the.followin
s;
10.Static Water level below top of casing; . i 0 • (ft.) Division of Water,Resources,'Infornlaiion Processing Unit,
.lf smear level is above eatilrg,use"+" , ` - 1017.'Vial:Serie Center,Raleigh,NC 27699-1617.
I1.Borehole.diameter:. 7 'Ll "(in:) 24b.For-lnleetion'Wclls:'In addition to sending,dm form to the address in 24a
fi
(,,t• above,aLeo submit.one copy ofthis form within 30 days of completion of well
12 Well construction method: VVI.UI't.- .irU I f' construction.to:the'following- -
.(ie auger,rotary table direct push,etc.) . - '
DivIsionofWater tesouiccs,Underground Injection Control Program, '
FOR WATER.SUPPLY WELLS ONLY: iv , 1636 ManSenice.Ccntcr;Raleigh,NC 27699-1636
' 13a Yield(gpm) 30 Method of test: 'Pt 11 24c,For Water Supply.&Infection Wells:: In addition to.sebding.tht-form to
' . the address(cs) above; also submit one copy of this form within 30 days .of
13b Disinfection type: ('1L� I'y' . . , Amount: )_ ' Q,(/ .-... 'completion.of'well..conslruction to the county health department of the county
'Where contra ted.
Fonn OW-1 North Carobna'Departmentof En'ironmelital Quality•Division of Water Resources, ---.Revised 2-21 2016