GW1--01346_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Con actor Information:
I areyy 6 . ,
la_F-lt, �,011 r I75 I4. ui RZOlrTG ;
Well Contractor Name FROM TO DESCRIPTION
�s 1�"ft. 1 Raft- CA., >/
ft ft. I
NC Well Contractor Certification Number ;: ;.. ,,
.ts011T'ER.CEStNG.(formarlti-c8seil fie1LK).tljLilAtER:(if:ap ticabtel <.:a Miller Well. Drilling • FROM TO DIAMETER THICKNESS MATERIAL
it.
t a ft. to S7Q2( PI/C
Company Name �J
O 1.,� / /�J 6 it NER GASIN OR:TUOIAG geotheitin eleSed,1660) :,:•. - KiK
2.Well Construction Permit#: -
( FROM TO DIAMKI R THICK NtSS MATNRIAI.
List all applicable well construction pennies,(i.e.UIC,County,Stale,Variance,etc.) It. ft. in.
3.Well Use(check well use): ft. ft. in.
,J'Ft:SCREEPF..:M,•.,>: ii£#;?i22...... :::tz;>i:i:><:><'.'t>>.:gs<z:>:-c;<.;:.,:-::
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESSS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft. ft. in.,l
❑industrial/Commercial 0 Residential Water Supply(shared)
3$GROffI_: .: a
❑irrigation ❑Wel Is>100,000 GPD FROM TO MATERIAL F IPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 3 ft. Arland R„ J
❑Monitoring ❑Recovery 7 ft. 26 ft. t��((on(f„_, 7 .)
injection Well: 7 ft. it. (x tK
❑Aquifer Recharge ❑Groundwater Remediation
:19i`SANDIGRAYEL.:FACK(tf:applicable) ii .„.:.::.... , .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 0:D11.1f.i$1VGL••OG.(attaehadditiuiirrlsheets.ifnecessaiv: it o <::_ ;. ;• ;::
M FRO TO DES IPTION(color•hardness.soiVrcl:type,„rain size,etc.)
❑Geothermal(Heating/Cooling�_Return) ❑Other(explain under#21 Remarks) ft. �0 ft. e Q`1
J
4.Date Well(s)Completed; .0-i'-22 Well ID# 2/_ ft• C'�J ft• otc e�h)nQ
5a.Well Locatio /17), a
/1UM
8+vzft• 42/C80ft. qrevO%P-a f Ir) � ft. ft. • -
Facili /Owner Name ' / Facility 1D#(if applicable) ft• ft. i-'t, `.. {}IVt-..;o
ft. ft. E t !
G172_1.e � _a n>z �c�l s3_t �
Phys'al Address,City,and Zip SF 3 It. ft. PIHft (J Q 2024 •
., ....... .. ......
liltOrM241P7l fir. ;,e,,i. Utit.,.
County Parcel identification No.(PiN) r�ZAYr(�-•v,w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i wU
Orwell field,one lat/long is sufficient) 22.Ce •icatio . 1
gc o,53 17 N 6834' 9)6' Y3 W ' •
/�2Z
s
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this turnt,1 hereby i•erti/).that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 121 9 15A NCAC 02C.0100 nr 1 S.-I NCAC 02C.0200 Well Construction Standards and that a copy
r7tiris is a repair,fill out known well construction itpnrtnatian and explain the nature of the of this record has been provided to the welt owner.
repair wider#2I remarks section or on the back of this form.
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 OW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: A01
(ft.)
For multiple well.,list all depths if different(example-3@200'200'and 2(5 100') Submit this GW'-1 within 30 days of well completion per the following:
10.Static water level below of casing: ��� (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR).
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water tirel is above calms use top 'Lh
11.Borehole diameter: (.1 f (in.) 24b.For injection Wells: Copy to DWR,Underground injection Control(TUC)
12.Well construction method: 4Program,1636 MSC,Raleigh,NC 27699-1636
{� �/il/(J 24c.For Water Supply and O en-Ltiop Geothermal Return Wells:Copy to the.
(i'c.auger,rotary,cable,direct push,etc.) /� 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
Permit Program,1611 MSC,Raleigh,NO27699-1 61 1
13a.Yield(gpm) , Method of test: l y i
L�I ,
13b.Disinfection type: I7't-IT Amount: /1-1 fj7 1
•
Form OW-I North Carolina Departmentt of Environmental Quality-Division of Water Resources Revised 6-6-2018