GW1--03015_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD For lntemal Use ONLY:
This farm can be used for single or multiple wells RECEIVED
1.Well Contractor Information:
Joshua N. Robertson 1144.OWATER ZONES DESCRIPITON
MAY 1 4. 1024 ft. ft.
Weil Contractor Name 127GPM@ 1-10'
2461-A ft. ft.
'IC:DEQ/UW1=1
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number
i;t'.)11Lfcll Office FROM TO DIAMETER THICKNESS MATERIAL
Triad Drillers, Inc. o ft• ft. in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
w24-0007 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Municipal/Public -
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) LResidential Water Supply(single)
❑Industrial/Commercial :Residential Water Supply(shared) ig.GROUT
FROM To
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 260-36i1• Thermal Pump
Non-Water Supply Well: ft. ft.
Grout
❑Monitoring URecovery
Injection Well: • ft. fr.
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft ft.
❑Aquifer Test ❑Slormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
l?lGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(colas,hardness,sail/rock type,grain sap etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 1-5 D, Clay
4.Date Well(s)Completed: 5/7'24 Well ID#9851122928 1 5 f; 260 cif. Granite
5a.Well Location: ft. ft.
Kathy Hawkins Campbell , ,T - i-
fL It �y.. , s.. _,:,
Facility/Owner Name Facility IDI1(if applicable) ft. rt.
6301 Dodson Crossroads rt rt MAY 2 0 1024
Physical Address,City,and Zip 21.REMARKS i f
Orange
County Parcel Identification No.(PIN)
511.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer'tcation:
(if well Seld,one fat/long is sufficieoQ /1 4i, or
/a(y�jri /'"" '� 5/10/24
N W
Signature Certified Well Contractor Date
6.Is(are)the well(s): ❑Permeaeat or OTemporary By signing this form,I hereby certi that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the welt owner.
If Ibis is a repair,Jill out known well construction information and explain the nature of the
repair under d21 remarks section aeon the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 6 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4@260 2@300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudttple wells list all depths if different(example-3@200'and 2ca 101r) construction to the following:
10.Static water level below top of casing: 80 (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8
11.Borehole diameter: (in.) 246.For Injection Welts ONLY: In addition to sending the form tothe address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&injection Wells:
13a.Yield(gpm) O-1 O Method of test: Air Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 16 oz. well construction to the county health department of the county where
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013