GW1-2022-01545_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
.) kn 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
WC Well ConbwtorCeedHoation/l�Jumber D ?^- 15. U TER' AMG rMuff' I wells RLI[BR Ittnble.-
1 A l 1 Z C-C-- C 1 U(- FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ©Q ft. in. Ct-Lto p�L
� © �� 1&DMR CASING OR TUBWG(geothermal closed400
2.Well Construction Permit ' o FROM TO DIAMEIRR TIUCKNM MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. t.
3.Well Use(check well use):
Water SupplyWeD: -17.SCREEN.
FROM TO DIAMETERS 9.WT SM TH[CEMM MATERIAL
Agricultural QMunicipal/Pubiic p & tt. Lin.
Geothermal(HeatingkCooling Supply) Residential Water Supply(single) ft. R. l;a,
_ Industrial/Commereial EIResidential Water Supply(shared) 18:GROUT t
h1lization FROM TO MATERIAi. EMPLACEtYIEWMETHOD& OUNr
Non-Water Supply Well: ft' (p ft' � ', -16 G k
Monitoring _ Recovery & & 0
lWecdon Well: ft.
Aquifer Recharge 13GroundwaW Remediation too
'-n
:.SAND/GRAYBL`EACR 1. Heable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL. EMPLACEMEi�Pf METHOD
Aquifer Test OStomuwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRU UNGLOG:attach additional sheets N
tym grain
Geothermal Heatin Coolie Rctum Other(explain under#21 Remarks FROM To DIssCR>p7YON color tmrdn sollhodc
ft' tt. Q.l
4.Date Well(S)Completed: 17� Well m# ft' ft'
Sa.Well Location: yy 'r
G�1�LC�oISrl-r-ylt rrl1 ft. ft. ro P\i STa�
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Facility/OwnerNamme Facility ID#(if applicable) fL ft. C��EJca�;O
ft. ft.
Physical Address,City,and Zip Z
77 21eREMAltl�l / .
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County � Parcel Identification No.(PII� t^ ►"r l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A-r 4
e
(if well field,one lat/long is sufficient) 22.Ce cation:
6.Is(are)the well(s)f3ermaneut or DTemporary —signore of Certified well Contractor Date
By signing this form.I hereby cert6 that the we11(s)was(were)constructed in accordance
7.Is this a repair to an exb tg well: DYes or To with 1 SANCAC 02C.0100 or ISA NCAC 02C A200 Well Construction Standards and that a
If this is a repair,fill out brown well construction lnfonnation 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 ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPP 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 attach additional pages if necessary.
drilled: SUBMITTAL INSTRIICTIONS
i
9.Total well depth below land surface: �-�t7 (fL) 24a.For All Weill: Submit this fort within 30 days of completion of well
For multiple wells list all depths if dfferent(example-3 t@200'and 2®1005 construction to the following: I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Pt m=Wg Unit,
If water level is above casing,use"+^ 1617 Mali Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
_y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (�o�/''1 construction to the following•. fl
(Le.auger.rotary,cable,direct push,etc.)
Division of Water Resouraes,Underground Indecaon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 2.- Method of test: `' n4c.For Water Snugly&Inlection Weiss: 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: 7H Amount: t t; ®to rt C f i completion of well construction to the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of water Reso i s Revised 2-22-2016