GW1--06181_Well Construction - GW1_20230922

n E.t.a.lA11,1I i nut,1 ION KECIJKU(CT W-1) For Internal Use Only:
1.Well Con actor Information:
�� ,n n ,fc,1
t7 s OP vv r)d r1 ..14.WATER•ZONES i 1 ,:' ._
Well Contractor FROM TO DESCRIPTION
1 f 5•-d 3_./` �Ob ft. /20 fL S� _ J
/ J /� � ft. lj m ��I,end
NC Well Contractor Certification Number / ;IS.OUTER'CASING(farniultiieits Velis)'OR•LINER-(Itop Miele)• "
'Blanc' o i '(� ie l.O, FROM TO DIAMETER TIIICNFFS5 MATERIAL
Company Name L+N l tv/G/t ,�/Z ii�t 9 Q9J it. z. fo. LG�J/w L0
.16.INNER CAASSIIINNG OR TURING.(peothctinal/etoscdtI0000pp)__I . ......
r'_.
2.Well Construction Permit t9: (N507A:2t •�/06 7 3 7 FROM TO DIAMETER THICKNESS - MATERIAL
List all applicable aril construction permits(i a UiC,CounrOt State,Variance,etc) ft. ft. 1 In. -
i
3.Well Use(check well use): fl. fL 1a
.17.SCREEN.. I •• -. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricuhural Di.MunicipaVPublic 26R it. t� fL Z. in, 1 / /ye) /UG
OGcothcrmal(Heating/Cooling Supply) Residential Water Supply(single) R. D. In. L..[
Dlnduslrial/Cammcrcial Residential Water Supply(shared) re.GROUT. .,,.• . _ - _"
-"Irrigation FROM TO MATERIAL EMPLACE1lEAT,UETIIOD&AMOUNT
Non-Water Supply\Veil: 0 fl. 020 it.
Monitoring ft,__ft- /�DU�' �1 1c�
Injectlon Well: it. ft. f
Aquifer Recharge I Groundwater Remediation
19.SANdioRAVEI MextirapPlleatife) .:..�_. '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ��� it. ��� h- Zi+�e�/�,E A „�n� �f
Experimental Technology In Subsidence Control tt. ft. I �`'
Geothermal(Closed Loop) OTrocer 20.DRiLLING OG•(attaeB additIonbI'sheee"s If.necessan).
Geothermal(Hearin Conlin Return) FROM TO DESCRIPTION(calor.hardness,satthock bye,grain size,etc.)
g Other(explain under/121 Remarks) R, R,
4.Date Well(s)Completed: Q `� B'!Z3 Well MN ft. ft.
•Sa.Well Location: _ ft. R.. I,
ft. . . -fe . s
'dew:#. Ne(.(,(Cty 4.... i - r. ... ,., i „+ f 7r ; ' 5:
Facility/Owner Name Facility ID%(if applicable) ft. ft. It R 't.L_%.,.r I„„i \t 4-.L.,I
/ aw rern c.e_ 2a,1A" r)0, ft.
". , ' SEP 7f173
Physiccaal�lAddress,City,and Zip ft. ft.
f, d.-� Co , It (e (, 7 7 21:REMARKS. . . . . ._.In6or7i-:;l NI•:-.:pia-.::;dflit'w. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: jr
(if well field,one lat/long is sufficient) 22.Ccrt111 on:
33 �`33 1 r N 7?a�f` 7 IC r' _ /
W 23
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6.Is(are)the Vvell(s)nPermanent or EtTemporory tare of Camilla Vcll Contractor D c
signing this form,I hereby certify thai the uell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: JYes or psi Nowith ISA NCAC OW.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repai,)It ont bum:,well construction information and explain the nature gratecopy aphis record/rag,been provided to the Well owner.
repair under 1)21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: r} p SUBMITTAL INSTRUCTIONS
9.Total Well depth below land surface: 1 (� n[,0 6 (ft.
24a. For All WcIls: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(arample-3@200'and 2@IOO') construction to the following: I. +
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10.Static water level below top of casing: i I c (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterinrl is above casing,use"+" 1617 Mail Senicc Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 5ly • (in.) 1
24b.For Infection Wells: In addition to sending the form to the address in•24a
v above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ilea(.r.d r( 4.+4 construction to the following:
(i.e.auger,rotary,Cable,direct push,etc.) ... - -.- - .
Division of Water Resources,Underground Injection Control Program, .
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,Z C Method of test: ft I Y(,, 24c.For 1Vater Supply&Inf ecction Wells: In addition to sending the form to
++ __ T 1 the address(es) above, also submit ono copy of this form within 30 days of
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134.Disinfection type: !4 Amount: rQ O Z • completion of well construction t i the county health department of the county
where constructed.
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resaurecsl Revised 222 2016
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