HomeMy WebLinkAboutGW1--05801_Well Construction - GW1_20230901 N
WELL CONSTRUCTION RECORD(OW-1) For.Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION'
NC WeII Contractor Certification Number / �ft ft. �� �� �
II ID (�� , FROM ER CASING(for mtDIAM ells)OR LINER(If$p'flwble)_
FROM TO DIAMETER' TffiCKNESS i MATERIAL
Company Name
/j2 At 02_0 ft. in. �a� "Of uG
f���/ ^ /y� / 16..INNER CASING OR TUBING'(Reothermalclosed-loop)
2.Well Construction Permit tit / l tl� ( 3-/C/I/b FROM TO DIAMETER THICKNESS MATERIAL •
List all applicable well construction permits(1•e,UIC,County,State,Variance,eta) R. ft. , in. -
3.Well Use(checkwell use): ft' i' to
Water Supply Well: '17.SCREEN '.. ' _ . . . `-
FROM TO DIAMETER' starsiZE TIIICK S MATERIAL
O Ageicnitutal OMrmuipal/Public /9 /O R, 2-- Ia / IS OD ,'Are
(Heating/Cooling Supply) residential Water Supply(single) • tL ft. in,
Oindustrial/Canuneecial UResidential Water Supply(shared) -18:GROUT ' - '. '
Olrrigatioa •- -l7Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT 14 on s. uhrr
Non-Water Supply Well: —D—it fix. tE
DMonitoring ORecovery ft. ft.�' ``*�''��r'e/at,)"
Injection Well:
UAquiferRecharge •UGroundwaterRemediation ft ,
19.SAND/GRAVEL'PACK Ill applicable)
OAquifer Storage.and Recovery OSalinity Barrier FROM TO M TERIAL EMPLACE/ulna METHOD
OAquifer Test DStormwaterDrainage /�(7 R.��.0 �r:i iQy'e/4Z .01/ /tie 6ar 4
CExperimentet Technology DSubsidence Control ft. . ft.
" OGeathermal(Closed Loop) OTracer - 20.DRILLING'LOG(attach addllloaal sheets if necessary) .. .
FROM To DESCRIPTION(color,haulms,sofVracic type,graindutete.)
DGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) f6
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d.Date Wells)Completed l 7 Z/ - _Well ID# •- - •. _h' • R'
:Sann.WellLocation: ,t:- n. ft ,
VA 1/�=�.lZAhu ri
"/" — - ft.' ft k 4.� i' s V vase
Facility/OwnerNama - Facility ID#(if applicable) „ ,. ,•
7g / AG�a. '' -;:< ft. ft. -.. i 1:-.- . , . .
- �°-_��?�h�ifJG_o�7�/2 .. .. ,� . SEP. J I 2023
Physi al A i ,.Address,C and Zip Qik7/ fL f� ' ' '
r D/11 21.RBMARK3 - i .. IRtvlir',311L.,t P1,..L.,,4,-v:.4l±f:.::
County Parcel Identification No.(PIN) '
R.Latitude and longitude in degreeslndmutes/seconds or decimal degrees:
Orwell field,one laUleag is sufficient) 22. (Mention: •
3tr
f?' 1/4'' N 'J 2 '201 3 8' w .0 Z 23
6.Is(are)the well(s):)ermanent or OTemporary SI Certified Well Contractor D
ci g this'forrn;!hereby cent fythat thewell(s)was(were)co'minuted in accordaacewith •
7.Is this a repair to an existing well: DYes or/°1No NCAC 02C.0100 or ISA NC4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
8.For GcoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only l GW l is needed. Indicate TOTAL NUMBER of wells (add'See Over'in.Remarks Box).Yon may also:stub additional pages ifnecessary.
dulled •
24.SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: (ft.) I:
For multiple welt list aAdeprhs ifd;Qereat(crumple-3@200'and 001� f t •
Submit this mind within 30 days of well completion per the following:
10.Static water belowieYeh topof,casing: (ft. 2Aa. For All Wells: Original form to Division of Water Resources (DWR),'
lfrwrrerrevel at er l vel use top
�� "rs ) Information Processing-Unit,-16171NSC;-Raleigh,•NC 27699-1617"'
11 Borehole diameter ', '. . 3 / OM) 24b:For Inlecion-Wells Copy tolthR,Under'grottndInjeetion Control(IUC)
, program,1636 MSC,Raleigh,NC.27699-1636 _._.. .. ....--...._
12 Weirconstruction method: �t I rO2 Vy ? t
(l.e auger,rotary cable,dhectpush,etc.) 7Ac.For Water Supply.and Open-Loon Geothermal•Return-Wens:Copy to the
-- county environmental health department of the county where installed r
_ rr
FOR WATER SUPPLY WELLS ONLY: _ t f
- � -• - '� over 0 0 :Copy to l).WR,CCECUA�'
.. .. .. 24d.For Water Welts Producing r 1 0, 00 MN
�/J Permit Program,'1611 MSC,Raleigh;NC27699-1611
-13a.Yield(gpm) -_3 Method of test: //9-/1"
13b.Disinfection typo: /f W Amount: to 0 Z
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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