GW1--04949_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECO •(OW-1) For Internal Use Only:
' 1.We o tractor.Informatio •
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i i •14.WATER ZONES - I,
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Well Co te FROM TO DESCRIPTION
�'.5 l 7-/-�'-- . .
' ° eta ft H.
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NC Well Contractor Certification Number fc fe
'� n A v F5.ROMft. CASING(for mnlfi-used wells)OR LINER(if ap liable)
Company Name (/v[�v ? �] y� FROM ft I TO ft I DIAMETER I THICIINESS MATERIAL
2.Well Construction Permit#: J /�C/50 2-6 O16. ER CAM SING OR TUBING(geothermal dosed-loop)
List all applicable well construction permits(I a WC,Corm slat VarianO DIAMETER THICKNESS MATERIAL
t1: 4 Variance. --�-' ft
85 ft. Fri- j�YZ�
3.WelI Use(check well use): ft ft �• j
Water Supply Well: • .17.SCREEN •
OAgricultural ❑IvlttniCipal/Pub1iC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL - ' •
ft ft in.
❑Geothermal(Heating/Cooling Supply) deatial Water Supply(single) -
❑Iadtuhial/Commercial ft. ft. in'
❑ esidential•Water Supply(shared) •
Okrigation FROM
GROUT
❑Wells>100,000 GPD FROM TO MATERIAL En1pLACEMENC METHOD&AMOUNT
Non-Water Supply Well: - ' D ft 2-3 ft. /)/94. n n sv- A
• ❑Monitoring ❑Recovery `v n�1 K
• ft ft
Injection Well: rOiPIA Y A.
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation •
❑Aquifer Storage and Recovery • ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETEOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION{color Lvdoess soWroektrpe Rrainsce eta)
ft ft •
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4.Date Well(s)Completed: 7-Zy-23 Well ID# • ft. ft r
5a.Well Location: ft. • ft
'T .S c r- 1 b e►- o el ft , �^ •
• Facility/Owner Name Facility RV(ifap licable) , ft. ft. ` •'b-" ''4-.,i t; L.
11�y 163 &- �n Rd • I-fir ' L.
ft ft AUG-!� 7 .?n73
ft
Physical A dress,City,and Zip ft.
/�/•� •
, , 21.REMARI{S,( ::;,::;:..-•,-...-..;,;:.-, ! ^vR.-„ao.:::tl 1J1:�7
County Parcel Identification No.(PIN) V'' r' 0`a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
3/ f , / t 22.C tion •
(' � N <33 • w. • / 7-3 2
6.Is(are)the well(s): P❑ ermanent or ❑Temporary G`3 Si •of ertified:Well Contractor . Date
7.Isthisarepairtoanexistiagwell ❑Yes or. 6V6 ! Bysigning this form,Iherebycertify that the we!!r war() (were)eonrS'anda in and that a with
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!this is a re oSthIlCAC dh :been provided
Dwell n Well Constraedon Standards and that a copy
j repair, out known n or commotion information and explain the nature of the of this record has beenprovided to the well owner.
'repair under#21 remarks section or on the backVIM: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 construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
(, t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` '(' V (ft) '
For multiple wells list all depths(MOWN(example-3Qa 200'and 2(4).100') Submit this.GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: G O • (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), •
Ifwater level is above eatin&:me 7-(j� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: CO / •(m) 24b.For Infection Wells:Copy to.DWR,Underground�d Injection Control(TUC)
12.Welt construction meth od: ����h/� j.�/Y_ Program,1636 MSC,Raleigh,NC 27699-1636
(i.e auger,rotary,cable,dagetpusl>,ere) ) • 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: • -
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
C/W
13a.Yield(gpm) Method of tech v Permit Program,1611 MSC,Raleigh,NC 27699-1611
is
13b.Disinfection type:, 1 1-k' Ambunt I® •a.'
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'Form OW-I North Carolina De
partment
Revised 6 6-2018 •