GW1--06837_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD (GW-1) For Internal Use-Only:
1.W l Contractor Information:
JgQt/� A' i i ( ' '
\ ail( C c- L A � 14.WATER ZONES I ..
Well Contractor Name FROM ft. To DESCRIPTION
e G`o :.N Inc, R. [ ft. I p , Gri)Al
R. ft.
NC'1Vcll Contractor Certification Number. �'` 1s.-OUTER CASING(for muiti-cased wells)OR LINER(if aA licable)
t i� FROM. TO DIAMETER , THICKNESS- MATERIAL
Y
NA- 4. ( H. 51( H. (o. .tf( Ia. 3 poi 4-( p VL
CotnpanyName
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#e e DP `, FROM ,TO DIAMETER THICKNESS MATERIAL
List all applicable nelhconstruction permits-,(t.e.:UIG County.State,Variance,etc) ft. ft. tn.
3:Well Use(check well Ilse): ft'. ft. to
Water.Supply Welii 17.SCREEN
FROM TO . DIAMETER SLOT SIZE ..TIIICKNESs' MATERIAL
Agricultural QMunicipal/Public: ft. ft.`: , in..
Geothermal(Heating/Cooling-Supply) esidcotiaIWater Supply(single) ft. ft. m.
Industrial/Commercial DResidcntial Water Supply(shared) is.GROUT
Irrigation. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: 0 ft' "24 R. /3,?,�,iL)/vire P imp
Monitoring jpftccovery ft. ft.
injection Well: ._._ .. --. .- - ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO .MATERIAL .EMPLACEMENT METHOD
Aquifer Test E3Stormwater.Drainage ft. . ft. .
Experimental Technology • DSubsidence,Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional:sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft' TO ft. DESCRIPTION(color,hardness,soil/rock type.(train size,etc.
4..Date Well(s)Completed:,C v 'a '2 Well ID# ( k V+ ft' g ft. S i�
ft. ft.
Sa.Well Location: i,
,q t r I 1iki ( 4 C ALL W ft. ft.
•
Facility/Owner Name FacilityiD#(if applicable) ft. - ft. • e• . i.
'/Via 4 ff fa. Crc�e mac►(,tr Ai( 'i S'Z- ft. ft. NO V I _ 2
Y y and ft. ft. _ : LD
4
Physical Address,City, � /
t C f 'c yt/ S 0'"tit)0l, 21.REMARKS if,:.,.., ..
County Parcel Identification No.(PIN): J✓ ' _
Sb.Latitude and longitude in degreeshn inutes/seconds or:decimal degrees:
(if well'field,one tat/long is sufficient) 22.:Certillcation:'
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6.Is(are)'the wel(s) Permanent or. QTemporaly Signatu f Ccni61) ua...d._ tb -2_ce-ly
Will Contractor Date
By signing this form,I hereby certify that the nvll(s)was(were)constructed in accordance
---7.Is this a repair to an existing well: .Oyes_ or wit,ISA NCAC 02C.0100 or/5A NCAC 02C.0200 Welt Construction Standards and that a
If this-Is a repair.f ll out known well conSinIClion 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 Ike hack of this form.
23.'Site.diagram or'additionai 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled; _ f� SUBMITTAL INSTRUCTIONS,
9.Total-well well depth below land surface: 3 (ft) 24a. For All Wells: Submit:this form within 30 days of completion of well
For multiple wells fist all depths ifdifferent(example-.3®200'and 2(.100`) construction to the following.;.
1
10.Static water level below top of casing:, - C (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: 10 (In.) 24b.For Injection 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: 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: /�ll" 1636 Mall Service Center,Raleigh,NC 27699-1636
te).13st.Yielet(gpm) '/' - Method of test:(kr n- l'l k---F. 24c.For Water Supply&Infection Wells: In addition to sending the form to.
r� the address(es) above, alsol submit one copy of this form' within 30 days of
13b..Disinfection I type: rc (�. Amount: • 1 t 6 completion of well construction to the county health_department of the county
where constructed. 1
FornOW-l. North Carolina Department of Environmental Quality-•Division of Water.Resources Revised 2-22-2016