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Home My WebLink AboutGW1--00014_Well Construction - GW1_20231218 * 1• 1 . . • • . • . . . . . •, . . . • . . . , . • , • • • 1 ; • • • . • - • . 1 , • • . WELL CONSTRUCTION RECO (GW-1) • For Internal Use Only: j '! • ' ......._ • • 1.W ntractor.Information: • ' i I . . . i_ (,,, LA../.. .. . . /),1,‘,t:r_jr.' . q i i • • - •14.WATER ZONES • • . - • • FROM TO mrscitirnoN . ll I I • Well Contractor Natsl t.._J 200 , .' ' .'' ' : .+.5.q 7-A • . . • . . ft. it• . .. I. - . . . NC Well Contractor Certification N 1 mber . . 15.OUTER CASING(for mulli-cued vvells OR LINER(if applicable) '. • ., • \ThAnnleladik., lid)". 1 • . FROM . I TO • ft. I DIAMETER 1 THICKNESS MATERIAL • ft. il 1 in. • • • , - Company Name „ • • .. IS.INNER CASING OR TUBING(eothermal eloted-loop) . . . . • 2.Well Construction Permit ft •a)7.:3 0-.3 g i ••• PROM TO DIAMETER. .7EICICNESS MATERIAL List all applicable wellconsitvaton pennfts(Le.WC cows%State,Variance,etc) . +1 ft. 53. ft. $ '41.' in* 7 h I C . p ve-: , • . • . ,3.Well Use(check well use): . . It 5 fi. 1 •1 in. . . 4 Water Supply Well: • • 17.SCREEN PROM TO • DIAMETER.I SLOT SIZE THICKELSS MATERIAL • • • OAgricultural • • •°Municipal/Public • ft ft' *- 11 tni • OGeothermal(Heating/Cooling Supply) ....14tidential Water Supply(single) • ' ft. - ft. • ' 11 fn.' ' • • • • Olndustrial/Commercial • .. OResidentialWater Supply(shared) 18.GROUT • 11 - -°Irrigation • •OWells>100,000 GPD • FROM • TO - MATERIAL EMPLACIZURF METHOD&AMOUNF Non-Water Supply Well: _' . - . - - ; --(-3 4- -2-f ft'' Ale41- An'ot.4 e.t. • 0Monitoring . °Recovery • ft. ft fteilg,. -P -rwr Al • Injection Well: • •-• • . . • • a ft. OAquifer Recharge • •' OGioundwater Remediation • 19.SAND/GRAVEL PACK(it epplicable) • • °Aquifer Storage and Recovery °Salinity Earrier . • • • FROM TO MATERIAL •EMPLACEMENT METHOD • •. I . 1 . 11 . . ClAquifr,r Test OStormwater Drainage . ft. ft -..‘ . . °Experimental Technology • °Subsidence Control . ft. ft'. VI I "; I • . . • • °Geothermal(Closed Loop) OTracer • , "20.DRILLING LOG(attach adaitional sheeb if necessani , ft. ' • ISCATIMQN(color,hardness,soil/rock type,train are,ze,etc.) ' °Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO D 11 ' 11. 1: .- • '.- :-.. • - • , . , • 4.Date Well(s)Completed:12-1 2.-Z3 Well 1D#- . • ft• .. .ft. ' l' I':I; • •• , ,I -. • .; •-.;.- , ..: .., 1 ... .•.• ft. . .' • : 5a.Well Location: ' •' •.. • - ' - . - ' • ; - ft. • '• .Tcurruu.).- D S 11 0 r.e._s '.. . . Facffity/Owner Name : •• Facffity IDS(ifapplicable) " • ' ft ' . ft '111 • i ., - 1-1:':tt :. F.', ' ..",,,P: ILV D •• 1 i ' : $ - 1 bC, (!aLl w)1/7 L n - 4-, kot • • - •-ft. .* ft. 0 1: •:, . •_ . . . - .,„t„.d. • ... DEC'.1 ' '' ^ . ' • r • Physical Addrest City,and Zip • ft. , •ft. II I' b 20 1 . , . 1. . . • . . • • • 21.REMARKS/ ll. . )1Arti • County Parcel Identification No.(PIN). II 11. • • 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1,, 1 (if well field,one lit/long is sufficient) 22.Ce .... 'oi t, . • .. 1 loj II i ii° N gio."<-5/ / aleS a• W ' ; a• * I --i i:-2,-3 Signature of,allettitatract • Date 6.1s(are)the well(s): Aermauent or °Temporary 2, 8 001 • - By:lining thli ions;I hereby cert* t the well(r)war(were)cOnstmted in accordance with 7.Is this a repair to an existing well:. °Yes or alNo• 15A NCAC 02C:0100 or'.75A NCI.02C.0200 Well Construction Standards and that a copy .- If thls is a repair,1111 out known wdl construction Information explain the nature of the of this record has been provided to tje well owner. .•, , , 'repair under DI remarks section or on the back of this form. 23.Site diagram or additional vell details: You may use the back of this p is toprovide.additional well Construction info• . • •. 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same . • (add'See Ovet'lull eniaricsBox).Yo-u inay also attach additional pages if necessary. • • construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled:' .* 24.SUBlVitTIAL INSTRU ONS li I . .. •' • • 9.Total well depth below land surface: 52-D '• (ft.) • . s"-' Submit thisOW-1 within 30 diys of wI ell completion per the following: , . Far multiple welly Uri all depths Y-ellffirent(example-3@200'and 2C4100`) . •' . . • • • (e, 0 • . •‘,.,, 24a. For All Wells: Original nn to Division of Water Resources (DWR), . • • 10.Static Water level below top ofcasing: t''‘) hifbnnation Processing Unit,16 MSC,Raleigh,NC 27699-1617 • .• • - tcwater level is above caning "+" •• . . . , . • , I . , 11.Borehole diameter:" 1.0 1( fan.) •-' . 24b.For Injection Wells:Cop to DWIl.,Underground Injection Control(11.1C) • . . •• - - , - .. Program,1630 MSC,Raleigh,NC 27699-1636 OA.4 •, - , . . '• • J.,..,- . • • 1 . -li t • - ' 12.Welt construction method: "2.)--13 kti -• ./ 24c.For Water Su 1 and 0 n-Loo Geothermal Return Wells:Copy to the • • am auger.!Am cable;disec!puck etc.) _ ' ., . .., : \ -. ' county enwronmen th dep ent of the cotmty where mstalled - ; • FOR WATER SUPPLY WELLS ONLY: •. • .• 1•,' • . , • 24d.For Water Wells rade! over;100,000 GPD:Copy to DWR,CCPCUA . . - • , I, 13a.Yield(gpm) _ . 9-0' Method of t est (1.1...1- • • Permit Program,1 11 MSC,Ral ghNC 27 99-1611 • . _ . ., 136.Disinfection type: 141 I+ Amount g • • . . • .• . • . • • , ' . . , • • ' . , . • . • , . . , •• , . • • . . . , •Form OW-1 ' North Carolina Department ofEnvironnwnta Quality-Division of Res , , . Rparie...1 se . . . Water , • . . , . . ..