GW1--03995_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.W II Co tr, for Info m ton: �
t. /11//j 14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorName ^/ 4 ,47 ft. V ✓7G eft. ca 0 pivi
(� �`yjl$-ft. Sri- oft. 4 t,6�
NC Well C tr,Idtor C rrtificati t/l Numbe 15.OUTER CASING multi-cased wells)OR LINER{if ap`licable)
!''�= / ' �/ �,� /y FROM TO DIAMETER THICKNESS MATERIAL
/I (ter /" !ll��� ` ft. ft. In.
Company Name
2.Well Co,traction Permit#:3 (3 %
/ 16.INNER CASING OR TUBING(geothermal closed-loop)'
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) /.-, ft. L'.L f'^� ft. / in '3)�''_ pt/e_
�//_
3.Well Use(check well use): ft. J l! ft. in. "
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural OMunicipal/Public ft. 'it. tn.
°Geothermal(Heating/Cooling Supply) B esidential Water Supply(single) ft. ft. in.
DIndustriaVCommercial °Residential Water Supply(shared) 18:GRou'
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6) ft. -�1G�,-- ft. Bul004 /1 C5 e�,,,z/r I2 'w'
Monitoring QRccovery ft. / ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft• ft.
t Geothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach additlonat sheets if necessary)
Other(explain under#21 Remarks) FROM TO I DESCRIPTION color,hardness,Loll/rock type,groin size,etc.)
Geothermal(Heating/Cooling Return)G ( p / 0 ft. ° ft. WG , j�444k) /2 aae
4.Date Well(s)Completed)-6"ij -;2V- Well ID# ( l:,ft. /y ft. 5Z 4 /� �„
5a.Well Location: .�l/o ft. /00 ft. .,...4,..„,, `®,cL,-T/r-``/
M;'�',f',101L ! . R(J,s�- `�SGS�"d� 7�f / >ft. 7 ) ft. u,N r �rL' ,'
Facility/Owner Name Facility iD#(if applicable) ft. ft. T
L.'
4/ 5A 0/15 4'[%CLS' /zd4.� Roar: lie_ ft. ft. F. t.•P..:''�!t.._
F'h}sical Address,City,and Zip (707 ft. ft. IIII 8 2024
k (�54 21.REMARKS ( iJ 4r:
unty Parcel Identification No.(PIN) t;:.�•" � !
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) • 22.Ceti''cation:
6.Is(are)the well(s)�ermunent or DTemporary
Signature of Ce ed Well Contractor Date
By signing this form,I hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 131C with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction litormation and explain the nature of the copy of this record has been provided to the well owner.
repair under#2i 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 I 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: f6 e,6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dderent(example-3@200'andd2®100) construction to the following:
10.Static water level below top of casing: .6 (ft.) - -Division of Water Resources,Information Processing Unit,
If water ley,.is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method; 4/4 /?ai<Mn y 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
Method of test:#�,k Li r- 24c, For Water Supply& Iniection Wells: In addition to sending the form to
13a.Yield(gym) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: }1 f !NZ- Amount: a dZ_ completion of well construction to the county health department of the county
where constricted.
Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form OW-1