GW1--07763_Well Construction - GW1_20231201

F
vvma.L.t.t.,11101KUC.IION ituEcC1KU(41W-1) For Internal Use Only: .
I.We C ntractor info ation: ............7—
• c J /•U A1.11V15/ I I4.WATER-ZONES, • . f i I/a : ,i,>.mar' . . _ ... _".. ' _
Well Contractor Name
FROM TO DESCRIPTION.
ESCRIIPPTION�/
. / ` - 3-4 7 d ft. se ft. I. Qncl
• 10 11 //U ft '4 rQ'r'+'r,11 enactor CC iHeaoNumb`/ '15:OUTE1tGASING(to_miilttased Wels)OR•LINER fife livable) •:p'rw / �i/ /// ��y -
FROM TO DIAM�EETTER T�RI ;//SS MATERIAL
e �/�/ifL �/� ft. l in. 'Ti/�'�G' l�(�.
6!-6' �,2�1ao v9p 1NER•C`ASINGORTU81AMETeothaima loop) _ ,.
2.Well Construction Permit N• i(/•J / U FROM TO DIAMETER THICKNESS •••ntATERrAr,
Litt all applicable well construction errors i.e.UIC.Corm%State,Variance.etc.) • ft. ft. In.
3.Well Use(check well use): t7. tt. in. .
t
r Supply\Yell: 17.SCREEN..FROM TO DIAMETER S TSIZE THICKNESS MATERIAL
ricultural °Municipal/Public fb ft. lj : in r� Aveothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. In.
ustrial/Commercial QResidentialWaterSupply(shared) 18.GROUT -gation FROM TO MATERIAL ERIPLACE.\iEA n1ETI1OO&AMOUNT
Water Supply We1I: rt. It,n
nitorig — ®Recovery �___ _ft._ D. . -' ,
- '- tion Well: • . f.uifer Recharge Groundwater Remediation 19.SAND%GRAVEL PACK(If applicable) - S ' .uifer Storago and Recovery DSalinity Barrier FROM[ TO tTERiAL EMPLACEMENTMETIIOD
uifer Test 0StormvaterDrainage f� fi• ` � R• Mperimental Technology 0SubsidenceControl . ft. faothermal(Closed Loop) Tracer 20.DRt LING•LOG tattsclisddillonal sheetiifnecs'iery) _.othermal(Heating/Cooling Return). Other(explain under 1121 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack tape grain drs etc.)
7 R. ft. .
' d.Date Wells)Completed: / /✓ Well ID# n• • ,ft.. •i•_ . , '
.5aWeil LocA
. , „• ..,
... _
. _ . " . _ .
_. . _ . . _ .. ..
FaeilirylOrvner Facility D (if ft. n.-
F tl ry! N applicable)
J/02 'fY/efl IGet?azvy/j , /(, n• it. - ...:- . , �; ..v;.}:I )
Ph cicaI Address,City,and Zip J n�r.
Pt £. (a 7 57 21.REMARKS. 1].j. ��Z�
County ParcelldentificationNo.(Pft) �n` - -.<:_
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: ^�`�,"'•� = a
(if well field,oonne lat/long is sufficient) 22.Certilic
�1!?G 7/ / rv� Ir N 9 �/]0 /!C�r 1(,/. " 1\' • I /. , �6.Is(nre)the wells) Permanent or °Temporary S0 extiticd W ctor arc . !J`
777777������ signing this AraI hereby ccrlJj'that the wells)no:(acre)constructed In accordance_
7.Is this a repair to an existing well: Yes or No rich MANCAC 02C.0100 or 1SA NCAC 02C.0200 lied Construction Standards and that a
Olaf it a repair,111l out ho,onn well construction Irtfort:ratio and explain the nature of the copy Olds record has been provided to the well owner.
repair under 1121 remarks section oron the.back of this form.
23.Site diagram or additional well details:
S.For Geeprobe/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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: n / SUBMITTAL INSTRUCTIONS . .
9.Total well depth below land surface; I pi l[o (ft.) �'
to For All f Submit this form within 30 days of completion of well
For multiple wells Nisi all depths if different{trample-3Qa 200�'and 2Q100) construction to the following: I I
IO.Static water level below top of casing: `7 (ft.) Division of Water Resources,Information Processing Unit,
Ifnater kvel Is above casing use•'+•' : 1617 Mail Service Center,Raleigh,NC 27699-1617
II.,.Borehole diameter: f - (fan) . . , 24b....
or'Infection Wells: In addition to sending the form to the address in 24a
12,\Nell conseructton mothade 11/1. fzs'�a.r�{/ above,also'submit one-copy-of this form-within 30 days-of-completion of well
t` construction to the following:
(i.e auger,rotary,cable,direct push,etc,) 11 - . . . . .::.. .... - - _-
... _. —
' .
Division of Water Resources,Underground Injection Control Program, ,
FOR WATER SUPPLY WELLS ONLY: •' _ '1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /[I Method of test: A-C� 24c.For Water Supply&Injection Wells: In addition to sending the form to
[[�� the address(es) above, also submit one copy of this form within 30 days of
Ob.Disinfection type: / Amount:, al a completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resou es, Revised2.22-2016
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