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Home My WebLink AboutGW1--02959_Well Construction - GW1_20240513 ' WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: - RECEIVED 1.Well Contractor Information: J t �/ lib Sr'/ 1/t l5 ,/ MA I 0 6 2024 14.WATER ZONES i Well Contractor Name FROM TO DE5CRtP�RON ft. ft. zi_5 7 4i' -- /(1 NC DEQ/DWR ft ft. . NC Well Contractor Certification Number Central Office .1S.OUTER CASING'(for multl:casedwells)'OR LINER(itdp Qedble) 11 AO TO DIAMETER THICKNESS I MATERIAL /e7 / S4rV � /r4/ i to- �� _ NO'/ ft. ft. 1 in. Company Name /� 16.INNER CASING OR TUBING(geothermal closed-loop) - 2.Well Construction Permit#: it//e5) 6-90 A V 7 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIG County,State.Variance,etc.) ts7 ft, ye yff/ft. /; In _ 4' i/ /' 'G>4//Gde: 3.Well Use(check well use): R. ft. is Water Supply Well: 17.SCREEN FROM TO DIAMETER, SLOT SIZE THICKNESS I MATERIAL Agricultural DMunicipal/Public 444 ft. ft. in. Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. M. Industrial/Commercial °Residential Water Supply(shared) 18.GROUT . Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: I. ft. O ft. .-// / Monitoring QRecovery • ft. tt •C'4460..Cj ,-7 rrttl Gr l Injection Well: ft. ft' Aquifer Recharge °Groundwater Remediation Surly _ 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD Aquifer Test DStoruiwater Drainage Ayr ft. ft. Exp 'mental Technology OSubsidence Control ft. ft. '' eothermal(Closed•Loop) E3Tracer 20.DRILLING LOG(attach additional'sheeta"if neceaeacy) ' - Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) • FRont. TO DESCRIPTION(color -hardn�+sail/rock type.entn size.etc.)�� Lri II. C ft Sc!Apt/y" r y 5,',/ 4.Date Well(s)Completed: 4 30,27i Well ID# 5 ft' 1-o ft. t 'L. / � r1 ti L f 5a.Well Location: 70 ft. /,LU it Gr 6,e,e GA 17.c-.+ t-,,,,j, - j ft. 4,0 I tt.T0Jir~' Ce.�re4A/ /7'i_ )l- SdkeP I2t1 i /w . `5e...)';i �,-1 C-/e,, • Facility/Owner Name Facility ID#(if applicable). a. ,940 ft. • /' • 5 S .5r dad/ Ad Au p. cm�) „Ce i'? Z‘O ft 305 ft. Pl e,,,,41 :b..,• . ..r44--1e-, ��_ Physical Address,City,and Zip / p ft ft. s t,;,,,..�",;1,`.t.`+I� f-, D/1 Ay e2 r? 5 76° 21.REMARKS Gv�,� �/ f� L 6! ` MAY I - 2024 County ! Panel[dcntification No.(PIN) / v�CC/ 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: If,.`.-r:;-•:,;.,, ^ °`- .'- (if well field,ono lat/long is sufficient) c r ' _ c! 22.Certification: 1 C• C:a.3_Ci g°3-glit eeri N t 5az.6e !�-- Z� !3 w l� c4 y,i---- g-.7U oAf 6.Is(are)the well(s) rmanent or Temporary Signature of Certified del]Contractor Date By signing this form,I hereby certify that the wells)teas(were)constructed in accordance 7.Is this a repair to an existing well: DYes or io with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,,fill out known well constriction Information and explain the nature of the copy of this record has been provided to the well owner. repair under#21 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 site details or well construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary. drilled' / - '0 SUBMITTAL INSTRUCTIONS i, ( 9.Total well depth below land surface: 6/ C`� /a Q I/ (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths y'dii different(example-3@200'and 2@100' construction to the following: 10.Static water level below top of casing: -45 (ft) Division of Water Resources,Information Processing Unit, If water level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617 II.Borehole diameter:-_ .._ (in.) i 24b.For Infection Wells: In addition to sending the form to the address in 24a / �1 above, also submit one copy of this form within 30 days of completion of well 12.Well construction method: /3 C/C/ /ill kei../ construction to the following: (i.e.auger,rotary,cable,direct push,etc.) I' Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 I • 13a.Yield(gpm) Method of test: 24c.,For Water Supply.&Inlection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: Amount: 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 Revised 2-22-2016