GW1-2022-01450_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use
L.341e11-£outtador Information:
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Well Contractor Na/m�e FROM TO DESCRIPTION
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NC Well Contractor Certificarion Number
�VG 6 (e Ga FROM TO . .DUMEM THICKNESS MATE111"
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Comp mN
2.Well Constrnction Permit#: FROM TO DIANZM I THICKNESS MATF.RUL `
list all MV*mble wff construction is o.a UIC,Couno?.Swe.VarfMke,etc.) It. ft.
3.Well Use(checkwell use): ft. ft. In.
Watertsupply Well:
FROM TO DIAMETER' .SLOT SEM THICKNESS MAujuAL
Agricultural unicipaUPnblic ft. ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL
Industrial/Commercial DReswenaal Water Supply(shared)
iron pn TO MATFdtLAL' CEMENT METHOD k AMOUNT
Non-Water Supply Well: & Zd ft' Q i r4 U�
Monitorin Recovery M ft.
ection Well:
Aquifer Recharge ®0mundwater Remediatton
Aquifer Storage and Recovery [3Salinity Barrier FROM To MAIMMAL EtariarBi cvn >~teriwu
Aquifer Test t35tormwater Drainage ft. ft.
Experimental Technology 13Subsidencc Control % ft.
Geothermal(Closed Loop) Tracer _ •�•:; = -
0eodrermal Coolin Return Other lain under#21 Ren>arks FROM To DFSCRTMON eotor-ea knbe, 0
�a-al-al �. 0 ft.
a.Date Wen(s)Completed: well 1D# h 4 3v ft• d fa r e Ae
5a.Well Location: v 6 ft' 23v n' i~e, h.t tB
7,4 err Y a- 6 te. SDI ft' rad A-1.
Facility/Owner N a Facility M#(if applicable) ft. ft.
h fL tt,
o P_
LU
Pimicai City,and ft. ft ,A��
C-EV Pawl Idend&tion No.(PIN)
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5b.Latftade and longitude or decimal degrees:
(f.,en r.try
tea'"^ '"'.•� AA.Cermicadon:
N w sal - •�� - �
6.1e(ar+e)the weks)dPermanent or Temporary Signature . ed Weli Contractor Date
By signing ihb forn4 1 hereby cenif+that the xvft(s)was.(were)coravucmd in accordance
7:L this a repair to an g veep: [ Yes or IONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Cbmtructim SSG andihar:a
Ifthis 18 a repair,fill ma writ construction b#ormadon and explain the nature of the copy efthis record has been provided to the well owner,
repair under#21 renarlrs jectka'aj am the back of this form.
23.Site diagram or additional well details:
&For Geoorobe/DPT oJe Giese&Loos Geothermal Wells having the same You may use the back of this page to pmvide additional well slte'detaiili or well
arty i t3W-1 is ticedexi.Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ffnecessary.
SIMW d'AL INSTRUCTIONS
9 Taw.well depth below.land surface: (ft•) 74a. For All WeDes Submit this form within 30 da
ys of completion of well
For mul*k Welk list all depths trdoerent(e:anrple-3@200'and 2@1001 construction to the following:
10.Static water level below top of easing: Z (ft) Division of Water Resources,Information Processing Unit,
(water level is above coot use^+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (�•) 24b.For Inier—don WeAs: In addition to sending the form to the address is 24a
r H`aYuvc,aiav ncuvusii vnc wpy ui n iorw wiiain 3v hays Ui cumpteuun tin Weis
12.well tonstruction rneibod: (� eonstnrction to the following:
(Le.auger,rosary:Cable,direct Pu914 etcJ
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Progmin,
l� 1636 Mail Service Center,Raleigh,NC 2709-1636
13s.Yield(spin) � Method of test: ���" 24c.For Water Susroly&hi"'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: 64 Amount: ( �.h. completion of well construction tti the county health department of the county
where constructed.
Foma QW-1 North Carolina Department of Environmental Quality-Division of Water Resonim Revised 2-22 207b .