GW1--00976_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only: •
1.C,hk
V,�eil Contractor Information:
rfi I ?W( lI. 14:WATERZONES . .. F
Well Contractor Name FROM TO DESCRIPTION
�0� • 6)O ft. ft.
ft. Igo ft. I
NC Well Contractor Certification Number
15..OUTER.CASING"(f it nulfi-cased wells)OR LINER(P'ap'licuble)t -:;`
D. L. 1'YI u,( 11 l s t k'�I`Dr 11 I i n . FROM it TO DIAMETER In THICKNESS `"MAATE,RIAL
Company Name �3 ft.
4t' 13 e3c �Y�t�
r 16.INNER CASING:OR TUBING eothern)al-closed-loo -- -
2.Well Construction•Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State,Variance,etc.) .•c_\ ft. •--r S- ft /_•1 in. ! `'Lc j� tom`
3.Well Use(check well use): ft l ft 1 in. �� vim+
4
Water Supply Well: -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural' 0 unicipal/Public ft ft in.
• ❑Geothemal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft in.
❑lndustriallCommercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENT MF.THOD&AMOUNT
Non-Water Supply Well: n ft. r°l�!o rt.' 11+�� _
OMonitoring ❑Recovery ftft. lDtl ��l��t'
Injection Well: ft, ft.
❑Aquifer Recharge ❑GroundwaterRemediation
-19.SAND/GRAVEL PACK(it applicable)' - •.:. -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer ;20.DRILLING LOG(attach'additional sheets if necessary)°:' '•.._. .,." _ .• .
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.)
DGeothermal(Heating/Cooling`Retum) U❑Other(explain under#21 Remarks) ft. �� ft '`�_ _l /�1 •
4.Date Well(s)Completed: t I 1 S 2 1 Well ID# �(/1 hf�Y t l 1l
t�Q ft V ft ` `01x1 , {�P�
Locatio •
Sa.Well .-t l.�p ft' 2SI�R' v�`Ue SIG
�`-�� t>r ft R. •
-
ft.Facility/Owner Name Facility ID#(if applicable) ft e, ""'' »"
ri"I`"IUlt--CAI US I U e D1 1_hrllt2/1 I{�aA I ft. ft. I rU 1� 0 LUL t
Physical
Address,City,and Zip ft. ft.
Iitr on cQ 7 lC1oo3 •21.REMARKS •`_• • . :.: .-.,.:"E• '�..>v..:_y ":;
County Parcel Identification No.(PIN) DWQ OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35, 1' m-12 1 N $6 r.s-8'3 2,9 w (Axel. A, l iis+2.
6.Is(are)the well(s): Vermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or (PIo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
23.Site diagram or additional well details:
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100')
4' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: kit) Information Processing Unit,1617 MSC,Raleigh,NC27699-1617
If water level is above casing,use"--" 1
11.Borehole diameter: ! ! (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
( Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RoTo•✓� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) J
county environmental health department of the county where installed
FOR WATER SUPPLY / •WELLS-� ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 V Method of test: Pt 4 Permit Program,1611 MSC,Raleigh,NC 27699-1611
I
13b.Disinfection type: I-iT Amount: 3 c,Lb'f-g