GW1--06095_Well Construction - GW1_20230921

ALL CONSTRUCTION RECORD For Internal Use ONLY: ' '
Thisfonn can be used for single or multiple wells •
1•. 1 Contractor Informaattiio/n: • -
I�GL t I I clJ�I FROdI14. ATER ZONES'. TODFSCRIPTION
Well Contractor Name IL ft.
43--- I2 A : : ft.
NC II Contractor Certification Number ' 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) . •
N� 1 FROM - TO I DIAMETER THICKNESS: MATERIAL
c S W€1 l ( i U-1 V S 0 ft � ' ib I e in. . !~(i;`.1
�
Company Name 16.INNER CASING OR:TUBING(geothermal closed-loop) ..
FROM TO I DIAMETER hi THI MATERIAL
�G
2.Well Construction Permit#: d 3 ' — 13 .-
1 04` ft. 4, - •
List all applicable well cansttncttonpermits(I.e.Count}:State,Variance etc.) it / In.
3.Well Use(check well use): 17.SCREEN ` •
Water Supply Well: FROM TO_ DIAMETER SLOT SIZ THICKNESS _ MATERIAL
QAgn
e.:. ..
'cultural ❑
l MnaicipaUPublia
❑Geothermal(HeatinglCooling Supply) irJResidential Water Supply(single) 6 -;
Oh dustrial/Commercial OResidential Water Supply(shared) 18.GROUT •
FROM TO . MATERIAL� N•.
Olt 'EMPLACEMENT METHOD&AMOU
rrngation � ft 2� tt`' fcA to d .(1 -.Conci-ci.
Nor.Water Supply Well: it. ft
Dbionitoring ORecovery :
ft.
Injection Well:
oAquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)•
FROM TO MATERIAL . EMPLACEMENT METHOD
❑.Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑4• •
quiferTest ❑StormwaterDrainage Lft.
❑Experimental Technology ❑SubsidenceContml 20.DRILLING LOG(attach additional sheets itne�sary) - •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(coter,tinniness,sallfreek type,grain size,etc.)
❑Geothermal(Hcating/Cooling Return) -DOther(explain under#21-Remarks)- -rO —LP ,,;ft!... ,_ 1 _(.O,-_di H_- -
4.Date Well(s)Completed: q— `(-13 `0 Jft' sCD -e I R 'ss'55 ��o •
ea
ciZ
S.Well Location:
(-0• 30-1P ft u3Q ✓ n.)c-c
COLS CO 44iI LL r'I^'_
ft ft .
Facility/Owner Name Facility ID#(if applicable) ft ft • .
a Sm aloe9 uct frt2• 11 . it. it. •C :;( - :�. 1 ff'.
•Physical Address,City,and Zip 21.REMARKS • •
OLtr\COAAsOn S 111,- SEp 9, I, '7Q73
County Parcel Identification No.(PIN) c .
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Y2 - cation: ; v^.`�+Z(
(ir.eu field,ono Ieti.loaa Is aufEo+ont) t// Jy
J Lfl �� R-(1 z3
f. N W i c9v,e1
_ . _ .
i Sjgeature ofCerti6 Weil Contractor Date
6.!is.(are)the well(s):Oerinanent or DTemporary By signing this form.',hereby certify that the wells)was(were)constructed In accords
with 15A NC4C 02C.0100 or 15ANC.IC 02C.0200 Well Construction Standards and th
7.1s this a repair to an existing well: ❑Yes or t21<o copy of this record has been provided to the welt Owner. i
.If this is a repair,fill out known well construction information and explain the nature of the I
rebair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
i , I You may use the back of this page to provide additional well site details or N___ _. __8 Number_of_wells constructed: construction details. You may also attach additional pages if necessary.
•Fqr multiple injection or non-water supply wells ONLY with the same consIreetton,you can - -24.Submittal Instructions: ' •
- .
submit one form. /�
-9:Total well depth below land surface: I O (ft.) 24a.For All Wells: Submit this form within 30 days of completion of t
For multiple wells list all depths rjdigerent(example-3(4200'and 2Q100') construction to the following: - ,
' '' 3 O Division of Water Quality,Information Processing Unit,
10."beater
water level top of casing: ( ) 1617 Mall Service Center,Raleigh,NC 27699-1617
If lsarer level Is above casing,use"+t
id
11.Borehole diameter: lLI � 1 (in.) 24b.For Iniectionl Wells: In addition to seading'the form to the address in
1 above;also submit a'copy of this form within 30 days of completion of
12..Well construction method: construction to the following: ,
(i:a auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground'Iljection Control Program,
13,FOR WATER SUPPLY WELLS ONLY: 1636'Mai Service Center;Raleigli,NC 27699-1636
24c.For Water Sumplv.&Geothermal Wells: In addition to sending the fon
1pa.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days
Amount: completion of well construction to the county health department of the col
13b.Disinfection type: where constructed. - .
•
.Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised;