GW1--06035_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1. ell Contractor Information:
(.14/ Ott f� . I •
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14.WATER ZONES 1 I I
Well Contractor Name M TO DESCRn'7TON t
LIB( -G f' 0240 ft I03plvl
ft. ft p
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if ap llcable)
Water Wizards Inc FROM TO DIAMETER n THICKNESS M TERIAL
0 ft 100 ft. C( I in. 5 (4) ¢UG
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. it in.
3.Well Use(check well use): ft ft. to •
Water Supply Well: Y7.SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
✓*Agricultural IDMunicipal/Public • ft, fL in.
111 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
N Industrial/Commercial DResidential Water Supply(shared) 18,GROUT
I Irrigation FROM ' TO MATERIAL ' EMPLAC ETHOD&&AMOUNT
Non-Water Supply Well: 0 it 1(10 ft. iv"ej`et- p4A!� t / 3&(6 s
®Monitoring Etlivery ft. ft.
Injection Well:
ft. ft.
®Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
®i Aquifer Storage and Recovery DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®*Aquifer Test I9Stormwater Drainage ft ft
®Experimental Technology jSubsidence Control ft ft. ,
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
111 Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks)
ft ft
4.Date Wells)Completed: '/223/Well ID#
� :f ft. ,5a.WeellLocation: ; 7:::(-.• '� ,; ;
`oVp 0 CA `41 N/�Q% f ft. I N.-c:.. t.,. . 4-`.i...,
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Facility/Owner N ame Facility ID#(if applicable) ft. ft. O C T 1 1 20Z4
4 5 I o 6
c -'O'gs 0`�m ie..c. ft. ft , x
Physical Address,City,and Zip ft ft IG+�:;s r•.t::::? t -
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O 21.REMARKS I, rot°rs:`,,,' '�u
County Parcel Identification No.(PIN) . t d to ,I ('"ems -efi4�+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CP4Selt
(if wellfield,J one la/ongg is sufficient) 22.Certification:
(..061616O2-1 N~7i/. '`/ //V( W
6.Is(are)the well(s) r nanent or DTemporary Signature of Certified Well Contractor '1 Date
By signing this form,1 hereby certy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or EllNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knoisw well constnrctien infomrotion 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 OW-1 is needed.Indicate TOTALNUMBER of wells construction details.You may also attaelt additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS:
9.Total well depth below land surface: 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(a),100') construction to the following: j
10.Static water level below top of casing: �� (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: 6L I (in) 24b.For Iniection Wefts: 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: a 0"r v construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 1 Method of test 24c.For Water Supply&Injection Wells: In addition to sending the form to
n r� the address(es) above, also submit;one copy of this form within 30 days of
14 13b.Disinfection type: I I Amount: ot.o4--"PS' completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016