GW1-2022-01147_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.well Contractor Information:
Al I- �, M WATER ZONES !
WellContractorWarne <r
FRONS I TO DF_4CRIMON
ft 11 O ft-
35y 1 - A16 'L tS " at eqa
NC Well Comer Certification Number 15 ODTER CASING formal&Deed w R Idl�lt da ble
fiffnz
Company Name FM
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� (,� 16 INNER CAS G OR TUBING thermal closed-loop)
0 O M To DIAMETER I�CIOIFSS MAiFBiAI
1 2.Well Construction Permit#: S 1
List all applicable well construction permits(i e.UIC,Cmmty,State.Variance.etc.) IL ft. is
3.Well Use(check well use): "' ". m
Water Supply well: 17.SCREEN
FROM 170 1 DIAMEM SI"rSUE TffiCRNM MATERIAL
Agricultural []Municipal/Public U f. R
Geothermal(Heating/Cooling Supply) CKResidentiai water supply(single) ft. R in
IndustriallCommercial Residential Water Supply(shared) I&GROUT
Irri "on FROM To MATERIAL CEMENT NgTROD&AMOUNT
Non-Water Supply Well: 6 R' 3 IL ou x&
Monitoring Recovery 3 ft C it. gin*il&
Injection well:
fL ft
Aquifer Recharge DGround'�Remed�on 19.SANDARUVEL PACK if applicable)
gt»fer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT M 111011
quifer Test DStormwater Drainage ft. fL
Experimental Technology Dsubsidence Control ft. tL
Geothermal(Closed loop) DTraccr 2&DRII.LING LOG attach additional sheets ifnemm
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTLON color t.ardoess,soltroek sae,etc)
� IL
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4.Date Well(s)Completed:1 Well lot/Ji l':6 0 tt 8
5a.well Location: / tL L.,,tt.,. r� j, ` ; . Ue
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tL
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Facility/Owner Name, Facility ID#(if applicable)
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�^ 1L ft.. 202�
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Physical Address,6tjG and zip fL ft.
` p Q (i b 21. EMARKS r O
R ! b
0©o5y3 L
County Parcel Identification No.(FIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.C cation:
`?fit, 1 lob N 1q . '5' w DA
6.Is(are)the well(s) Permanent or Temporary Sibiaruic.of edWeRiConU-&Llore,4'� Date
1�a 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: Yes or 170No with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill oat known well construction information and Agilain 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 iattach additional pages if necessary.
hued' SUBMITTAL`INSTRUCTIONS
9.Total well depth below land'surface: 5 (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells/at all depths ifdifferent(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: o (fk) Division of Water Resources,Information Processing Unit,.
I water level is above caving are'+"
J g. 1617 Mail Service Center,Raleigh,NC 27699-1617
11-Borehole diameter. (tn.) 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.
Pt 12.Well construction method: I Q, 191)".a eonstructibn 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
13ii.Yield(gpm) 5 Method of test- t 24e.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: 1 f omout completion of well construction to the county health department of the:coumy
where constructed.
Form GW-1 North Carolina Department of FBvi u mental Quality-Division of Water Resources Revised 7-22 2016