GW1--05886_Well Construction - GW1_20230918

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ' ' '
i, F)4, 1f, A-6i.yt h d hi-it 14.WATER ZONES l
Well Contractor Name FROM TO DESCRIPTION ��[
/ ��jj ft. ft. ��/` J' o p r�
r2 2/ " 4- Q :/
�� fL ft. f21 u
NC Well Contractor Certification Number )J C� 7d day,-Pn,
15.OUTER CASING(for multi-cased wells)OR LI of ap licable)
`� / / O { /7 C t FROM TO DIAMETER THICKNESS MATERIAL
/!l r / 1 �' �/Lfr. �i/ii�t. d: in. ,5'if z t/ p i'c-
Company Name ' 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit#: r� a 9 v g FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 6.e.UIC, ounty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OMunicipal/Public 0 ft. ft. in.
*Geothermal(Heating/Cooling Supply) 1M `esidential Water Supply(single) ft. ft. in.
I Industrial/Commercial D Residential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 8 ft. g„„/.h. °. Oft t/ i f„J y /Dori Aw-
n Monitoring .Recovery ft. ft. l /
Injection Well: �'�'"/�1� t
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Ili Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®Aquifer Test DStormwater Drainage ft. ft.
*Experimental Technology D Subsidence Control ft. ft.
11111 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) •
II Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks). FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae etc.)
v ft. 5-/ ft. I3,t,K�Cht,:. L. .
4.Date Well(s)Completed: 5'-//-2 3 Well ID# / ft. Or ft. *"J �,
Sn.Well Location: g q%, ft. e1C/ ft. ,t�...,C
"� ft. ft.
0'•r,, A).7 ,o111.5 ft. ft. ,=r ` ; j _ 1!
Facility/Owner Name I_ Facility ID##(if applicable) -�';f+ t 1 I ,E )
4 o f .S 7h4.. / 4,-,,,s A i-40,2rlar EI� ft. ft. ,`` t� p 8 }
Physical Address,City,and Zip ft. ft. J I 1 ZO`l
r Q r 21.REMARKS •
14 1,-e7 1[]�j -6 /`4[ c7Ste intoims:l iI:mot:-l.�a :4 lrA
County Parcel Identification No.(PIN) 1`ant'li.;
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �i 22.Certification:
ll
" �f ra -Jly6.Is(are)the well(s) er nanent or DTemporary ),j4
nature of Certifit Well Con clot Date
�� By signing this form,I hereby cell fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or ofVO with 1SA NCAC 02C.0100 or 1SA 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:
8.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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '7 dio1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6, (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: I(u 74)11 1 construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test: f'".//"('I 24c.For Water Supply&Injection Wells: In addition to sending the form to
� the address(es) above, also submit Pone copy of this form within 30 days of
136.Disinfection type: C 1,/t)1".n z Amount: 1 completion of well construction to the county health department of the county
where constructed. I '
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-20 I6