GW1--05343_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.W II Co tr for Infoymsgtion��
1 yl "`�/9j/'� //� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
P -2 - ,,Uat. _ y'ft.ft. �^/`(L7 ft.
NC Well C traefor C friend Numbe
t 7 GJ51 / / �y 15.OUTER CASING(for multi-cased wells)OR LINER(if ap liable)
/��= � /� /��/" `••7 //v FROM TO DIAMETER THICKNESS MATERIAL
!�� / ✓ !/ ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Co,[ruction Permit#: 1�7t�y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction rnuts(i.e.UIC,County,State,Variance,etc.) O ft. _5-3 ft. U/_ in. /S,� (/�p
3.Well Use(check well use): ft. ft. in. (!
Water Supply Well: 17.SCREEN
FROM TO
Agricultural QMunicipa1/PubIic ft. ft. DIAMETER SLOT SIZE THICKNESS MATERIAL.
In.
Geothermal(Heating/Cooling Supply) csidential Water Supply(single) R. ft. in.
jIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
I-1 In-igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,
�0 Scy4~' A�' / /- � �5` S
s Q
(Monitoring 0Recovery ft. ft.
��rt/ r��
Injection Well: ft. ft.
°Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery
Aquifer Test
19.SAND/GRAVEL PACK(If applicable)
Salinity Barrier FROMTO MATERIAL EMPLACEMENTDIETHOD
0Stolmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO MTo DESCRIPTION(color,hardness,soltrock type,grain size,etc.)
d t. o 8,)„ cep
4.Date Well(s)Completed.. '' ay Well ID# 0/V1-: �6) ft. c... L
ft. r)444, J t
13
Sa.Well Location: 3� fft. l 0
ft. f./a Ai i',L J`—
Cl/1/ LJiiG/I ia/U N r7 O 00'/- 6✓3 D ft. ft
441
f r1 LUGt�
acuity/OwncrName Facility ID#(if applicable) � 4
Physical Address,City,and Zip ft• ft. ........ ... '`. _ ,i .1
/4
1)/6/2)( _ 21.REMARKS J e p V 2074
County Parce_ldentifution No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cell''cation: c• - '
,yl 3' �
19; - 1 N � l�. 71 34G�ir
W 1p�_
6.Is(are)the well(,) ermanent or Temporary Signature ofCe ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or PC with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conunuction 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: A/Y/4 SUBMITTAL INSTRUCTIONS
9.'fetal well depth below land surface:d 75 (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple use/Is list all depths ff'dierent(example-3C200'and 2(Qa/00) construction to the following:
10.Static water level below top of casing: f c (ft.) Division of Water Resources,Information Processing Unit,
If water lev..is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
/, 1/
11.Borehole diameter: l a (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: 2 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: -i'Q,/jh1,/ 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:0/7 Ld.iWG Amount: i3,,S ocivIes 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