GW1--03460_Well Construction - GW1_20240611

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14::WAi`ER ZONES '
Wel Contra ame 3 ` FROM TO DESCRIPTION
DESCRIPTION
• (4 v ft ��/+' ft 16 asem
�- � ft. ft
NC Well Contractor Certification Number 15;ODTER:CASING:for multi-cased welts OR LINER if a 7icabie z ,
Mor an Well&Pump, INC • unzjmwimm DIAMETER THICKNESS MATERIAL
I) ft. 1�' ft. 1 618 Is. sir-21 PVC -lam
-'1` 6 & ING INNECAS OR=.TUBING'(geothermaitlosed loopy- -. __ _-
2.Well Construction Permit#:_ t.' (.7�`^���j FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
' 3.Well Use(check well use): ft. ft. in.
Water Supply Well:
17:SCREEN :.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. it. in.
J Geothermal(Heating/Cooling Supply) NgiResidential Water Supply(single) ft ft. in.
'Industrial/Commercial Residential Water Supply(shared)
18:'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft' bentonite poured
}Monitoring Recovery ft. ft.
Injection Well:
ft, ft.
nAquifer Recharge Groundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Q'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
_ Aquifer Test
I Stormwater Drainage ft.
go
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer ft.
DRILLING (attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
r} n ft Zb ft. rtd ctlr-�
4.Date Well(s)Completed:,�'�( /' i+Wel1ID# 'ft• ft•5a.Well Location: "3 a ft tkS ft tv,eto ta, roc,t_
Facility/IOwwnner Name W.
c Facility`` ID#(if applicable)/ ft (� ft ` r L. a `. f '.,
3.�P 1 i(iS L�c.���Y �{ kg c - I. ft. ft. r, :'����
ical Address,City,and Zip —}�+ /� ft. ft. I N 1 ?U 1 Y
3� D b)` `o 21.REMARKS
County Parcel Identification No.(PIN) '`^,,ICU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
onec (q lat/long is sufficient) 22. ''cation:
. S. el[AA N 1.6.�C295 W
Con43)
6.Is are the wells _Permanent or TemporarySi f ifie Well tractor Dat
By signing t orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or )No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I JK (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example- and 2@100') construction to the following:
10.Static water level below top of casing: 3S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one 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
13a.Yield(gpm) \() Method of test: air 24c.For Water Supply&Infection 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: granulated chlorine Amount: 4 nz 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