GW1--01882_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECO
(GW-1) For Internal Use Only:
,gt: ,, . :.. , 1.Well C Era Into ( I _
L ••• S . 1R•tel-ecj ci✓
•14.WATER ZONES . !
WellCoatmetorName FROM TO DFSCR1PTlON , - -
,3 $ 35 ' '• a�Q b !°' ioo ft. �I -
NC Well Conhaaor Certification Nuaober ft tt �i •{ •
•
• 15.OUTER CASING(for multi-cued wells OR LINER(if ay liable) •
•`�.C�yri ct.m. Jj/�(9 i-h-^! . FROM TO . DIAMETER 18ICIUYFSS g MATERIAL
' - Company Nan e I •' ft. '', in
2.Well Construction Permit#: 16.INNER CASING OR TUBING(geothermal closed-loop) ' ' . . -- •
(�4A;Cd`'t-' (,t . • FROM TO DIAMETER •• TBICIINESS. MATERIAL' •List all applicable wellConstnmBon permits n e.UiC Cormry,Stair Variance,eta) -•(•I 'ft n' 7.)1 Ili
,
• •. 3.Well Use(check well use): • • tt ft. + ; in.
ater Supply Well: , ,.' . 49.SCREEN ! i
gricultural '❑lvlunicipal/Pubhc FROM TO DIAMETER SLOT SIZE TffiCIOVESS MATERIAL
ft R
,OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) '
Olndustrial/Commercial n iO
❑Residential'Water Supply(shared)
l7lrri'gation - 18.GROUT
❑Wells>100,000 GPD.. FROM TO • • MA'r'ms4s.. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' • :'- , 0 ft. .2 y' .m 11/L'A t-
❑Monitonng • ❑Recovery ft M s�"r"(
Injection Well: tt Ur f ftliwl . p t;�.;,s./l
• ❑Aquifer Recharge, • ❑GroundwaterRemediation h•
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVELPACK(if applicable)
• _ _ = PROM - .To MATERIAL.-- EMPLACEMENT METBOD. !?Aquifer Test ❑Stonmwater Drainage •
❑Experimental Technolo
gY ❑Subsidence Control R
❑Geothenmal(Closed Loop) •- " '❑Tracer• '20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO • DESCRUPTIQN(color,hardness,soiJraek.. •- ".. ) tt hra ersla aia,etc)
4.Date Well(s)Completed: Z-!R�Zs} Well ID# t, -.,''"'_.e 1 E �(, ", ,y'it L WI-44 ;
Sa.WellLoeatioa: MAN 2 7't • tt anr''� I 'ee •�
' 'SWeeks' trV o lI Qvtl carirn ' � - a, 'tee of ' :.
Facility/Owner Name ty • .
Facie Mil i�{:�'Sf�,:?�'1✓ ft. , .
' ' • 1 al— ( /ail, Veil n C- � �
Pd 6WYI eYS
hysn' , Qdress,City,andZip • ft. R
lNl�.l ' z1.REMARIGS!^ may-��County 'Parcel ldentifiation No.(PIN) p.► t ►•t -R 7 e)Y '
�a
56.Latitude and longitude in degrces/minutesfseconds or decimal degrees: {'
(if well Sald,one 1stllong is sufficient) -
/ _ ,)u t ,L��� O r 22.'Certification: -.' i�
d0 • T N O! d 31 7i�i', ytr 4 1�is1 '•
6.Is(arc)the well(s): permanent or ❑Tam ors / Z-2— 2af-
e 1 C P rY _L._:ca S��- . Sigh,. of eitifig,gF l Con dcdor.:_:•. Date
ing this
7.Ls this a repair to an existing Well: • ❑Yes or/�1No• -1.t NBC IC.02C 0100 oerr'TS.Y NC AC 02C.0200 ceri0 that the (Well Co Cron Standards and accordancecoartructed in copyi
If this isa repair.fill out blown well coartnrcion injormanon explain the nature of thi • of this record has been provided to the well omen
, . : 'repair under#21 remarks section or on the back of this form. , • • • • -
' 23.Site diagram or additional well details: '" ' • _
' 8.For Geoprobe/DPT or Closes-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 Remarks Box).You may also attach additional. • ' drilled: pages if necessary...
24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface:. • c •!� ft
Formultlple wells list all depths•
if different(example-3Qa 200'and 2(a)(00) ( ) Submit this GW 1 within 30 days of well completion per the following:
•
below top of casing- 6 0 • (ft) 24a. For All Wells Original form to•Division of Water Resources'(DWR),''
NI.Static water level
Ijtvater level is above actin&;ure +iic> Information Processing Unit,161T�MSC Raleigh,NC 27699-1617
" , 11.Borehole diameter: �
-(in.) . 246.For Injection Wells:Copy to DWR,Underground Injection-Control
n Prognun,1636 MSC,Raleigh,NC"27699-1636 C)
•
12.Well'
constructio m •n ethod I`D 4-a{-s,,�(1.....4......•
(i a auger,rotary,cable,direct pwb,etc) •
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the county environmental health department the county where installed
FOR WATER SUPPLY WELLS ONLY
24d.For Water Wells producra(t over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) L+- ' .• .. Method of test: t � • '• Permit Program,1611MSC:Raleigh,'NC27699-1611: ri. ,
" •• 13b.Disinfection type:• N 7 t'1 . Amount: ' - ,/.Z w • _ ) t
Form OW-1 { i
North Carolina Department ofFnvuonmentsl uali f,•
Q ty-Divi:ionofWaterRe§aurees _ ;