GW1--06314_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECO (CAW-11 For 7;7nd l Use Only: ; •
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1.Well Co or.Information: a '
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•14.WATER ZONES .!
Well Contract rN FROM TO DESCRIPTION
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9 5 C1 7 —A. /oo �' oo I '; •
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N ell Contractor Certification Number 15.OUTER CASING(for multi-cued wells)OR LINER(if ap linable)
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.J_4A f l 1 v I j /l _ / •
FROM TO DIAMETER THICKNESS MATERIAL
Company Name
1 I a 2 • 16.•INNER CASING OR TUBING(geothermal eloded-loop)
2.Well Construction Permit#: ( v� Oil FROM TO. DIAMETER THICKNESS MATERIAL ..
List all applicable well construction permits(Ie.flltn Cotmry,State,Variance,eta it 2.4 ft. In.
3.Well Use(check well use): ft. fL (I': fa
• Water Supply Well: kl.SCREEN
['Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL- • '
gn 'OMunicipal/Public ft. _ ft. ... .I lin.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) '
❑Industrial/Commercial dential'WaterSu l 'm
• Supply(shared) 18.GROUT ,'
Olrigation OWells>100,000 GPD ._ FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT -
Non-Water Supply Well: ,. -0 ft 23 ft n /�r _ A A ,7e ( N
• ['Monitoring ['Recovery �11 14 - r
Injection Well: • p0Yllap e"`""'"/
0A uiferRechar e I d
9 g DGroundwaterRemediation
['Aquifer Storage and Recovery ❑Salim Bruner 19.SAND/GRAVEL PACK(if applicable) •
ty FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test • OStormwater Drainage I ft ft.
• ['Experimental Technology ['Subsidence Control it ft u ` :
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• ['Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DLSCRIPTION(color,hardness,toNnek type,gram roe,etc.)
•4 Date Well(s)Completed: f?�iy zJ Well ID# • it ft
5a:Well Location: T
ft R
J its4-1 h ClaII i n } . . n it
• Facility/Owner Name Facility ID#(if applicable) . ft. it P rc �?•\i 1 L k It
Zoo n-e �arY+Oo1) 'Rd' — •) rrl` ' _ "• - «_ �
Physical Address,City.and Zip ft. ft. S t N . 6 2023
I ki a+-o L G a 21.REMARKS./County - V - _ t 1f1S'.;11,,, 7il 7} /rY:.:,,r v%.r -
Pareel Identification No.(PIN) •�' Dr,nnt,SrX
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: E
• (if well field,one letllong is sufficient) 22.Certific •on: 1
��' 1D ' I�' N �� P. �35 ' .5b ' ,,W . � •?
- 6 Is(are)the well(s): ermanent•. or OTem ora 1 Signunra fC'ti IlCanna r _ / - Z3
P Date ,
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By signing chi Arm, reby ceriifr that the well(r)was()rare)constructed 1n accordance with
7.Is this a repair:to an existing well: !lYes,or 111o' 1SANCAC 02C:0100 orISANG(C 01C.0200 Well Construction:Standards and that a copy
IJthis is a repair,fill out known welleonsiruetlon information miff&plain the nature of the of this record has been provided to the well owner.
'repair under 121 remarks section or on the back of this form.
23.Site diagram or additional well details: r
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rdmarka Box):You may also attach additional pages if necessary.
drilled: • i', .
24.SUBMITTAL INSTRUCTIONS '
' 9.Total well depth below land surface: aQ
- For multiple wells list all depths rent(example- 00'and2Q1001 (f b) Submit this GO-1 within 30 days of well completion per the following:
10 Static water level below top of casing: �� (ft) 24a. For MI Wells: Original,!form to Division of Water Resources (DWR),•
If water level Is above casing: a"+ ` Information Processing Unit 16l7 MSC,Raleigh,NC 27699-1617 . •
II.Borehole diameter: (in.) • ' 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)_.- ,
. Program,1636 MSC,Raleigh,NC27699-1636 - . .
12.Well construction method: - - -
(i e.auger,rotary,cable,direct push.eta.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
county environmental health department of the county where installed • -
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin F over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1513 -'20 0Method of test; ' Permit Program,1611 MSC,Raleigh,NC 27699-1611 r
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13b.Disinfection type: Ik- R . Amount: •
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resor reef
Revised 6 6 2018