GW1--02414_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
if e6 I.er 4/r'sS w,oe�
� 14.WATER ZONES I ;
Well Contractor Name FROM TO DESCRIPTION
V 3 7 5 - f•
t. ft it/
NC Well Contractor Certification Number ft. B'
IS.OUTER CASING(for:multiIcaeedswells)OR LINER Map Ucable)
70 I �L`fr/1i i_ Go FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 40 ft, i ft. I i in,
Id.INNER CASING OR TUBING(geothermal closed•loop)
2.Well Construction Permit#: ti/6 6 6 a cZ 471 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',Count,State,Variance,etc.) /i//� ft. ft. In.
3.Well Use(check well use): �%� ft. ft. in.
Water Supply Well: 17.SCREEN •
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public
1Geothermal(Heating/Cooling Supply) f Residential Water Supply(single) �'l/�ft. ft. In
it Industrial/Commercial I�`Residenria O• ft.ft '
—i Irrigation I Water Supply(shared)
18.GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v! ft. 0 ft.
®i Monitoring Recovery �hr/+',G /rr.,,�,•,.•� ic2e..
Injection Well: ft. / p
IaQt4.c. P",•-•s s /., r- oys)J i-
1 Aquifer Recharge jGroundwater Remediation ft. ft. S 46/
Aquifer Storage and Recovery19.SAND/GRAVEL PACK.(tfapplicable) .. -
,I Salinity Barrier FROM TO MATERIAL •
*Aquifer Test [Stormwater Drainage ft. ft. +, EMPLACEMENT METHOD
•Experimental Technology (Subsidence Control ft. ft.
.
IRO Geothermal(Closed Loop) DTracer
20.DRILLING LOG(attach additional sheets If necessary)
I.Geothermal(Heating/Cooling Return) j�Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saWrocic type.grain sire,etc.)
/ (9 ft. ft'
4.Date Wells)Completed: .}1i 1 '.v2 V Well ID# 5 ft. ft. Ir.),.?
�ir'die c", $�, ��
..of G/cq t//
5a.Well Location: g, ft. I /
Ni// )>. / / 7o PO 4.<kr. a Se.9e/
t:P Go,,,,/r /T ,h ,5,48 /to ft. i0,0 ft 7;iit Sanb L/y/,
Facility/Owner Name / Facility ID#(if applicable) ft. ft.
r / / /� I / MC emir U s If,',it f /.�i�c✓n c-/4r
�J 0-4- 7 �G 14 e / /t t!r /)of e 1,-e->i arl-f Ito .260 ft. 305 ft i
Physical Address,City,and Zip ft. �"
ft. ,' e ✓.a ..C.4
C/r w
f/• 2L REMARKS
f¢�l'r /�t>J�/�1/ ti 'l.%.,... tL.-.t •r a,:..:..,.
County ( Parcel Identification No.(PIN) !
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: A f t R 2 2 LO7h
(if well field,one lat/long is sufficient)
o t G7- ('c%,i 22.Certification: ! lnfG:i; t r'r-,^;r:,-,y'Jrsv
w
6.Is(are)the well(s)I ermanent or Temporary Sign lure of Certified Well contractor Date
~(�.. ��
,...."....,
iiii
rm,I hereby
that
was
were)
7.IS this a repair to an existing well: Yes or No twiht SA NCAC 02C.0100 or 1SArCAC 02C.0200)Well Consr Construction Standards and that a
If this Isa repair,,fill and known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of thls foiwt.
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 site details or well •
construction,on1 1 G 1 is needed. 7rjdicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: $ ec, c"qs / Hoyt —ltdf I.
SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: JO For multiple wells list all depths ydijlirent(example-3@d00`and 2@ p0 (ft) 24a. For All Wells: Submit]this foal within 30 days of completion of well
/t construction to the following: ;
10.Static water level below top of casing: �
() ( )
!flatter level is above casing,use"+" Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Infection Wells: In!addition to sending the form to the address in 24a
12.Well construction method: /7,, f ,, � �tf above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) ( construction to the following: '
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Servi�a Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: Amount: the address(es) above, also submit one copy of this foam within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revived'I-79_7t11 4