GW1-2022-01594_Well Construction - GW1_20220204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
n 11 _-
P 14.WATER ZONES
Well ContrAor Name FROM TO I DESCRiCrION
("a-3 "- I awn 3 M
3s4 i NC Well Contractor Certification Number Igo ft- 90 ft- a G- h-,
15.OUTER CASING for mnW maid*A! OR LINSIt ifa ble
AI I_thJ'"`S W P I I�r i 1,I n.Ci I n c,. FROM T 1 DIAMETER I THIC MESS MArtItIAL
Company Name If-IL I `tq R' 4 m t D 2.5b V C,
16.INNER CASING OR TUBING thermal dosed-loo
2.Well Construction Permit#: `�2 3 �S
ft-
FROM TO DIAMK ER 7WCXNESS MATERIAL
List all applicable well construction permits(Le.UIC,Comity.State,Variance,etc) B- % in
3.Well Use(check well use): B' & in.
Water Supply Well: 17.SCREEN
FROM TO I DIAM9M SLOT SIZE TWCENEW MATERIAL
Agricultural ElMunicipaVpublic 0 tL tL in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R tL in.
Industrial/Commercial Residential Water Supply(shared)
1>i GROUT
Irrigation 17:
TD MATE IAL C<'2dF W MEPBOD&AMODNT
Non-Water Supply Well: D i.(- Monitoring QR--UfLInjection Well:uiferRecta
Aq � to
urge �GrotmdwaterRemediation
19.SAND/GRAVEL PACE der 'cable
_ Aquifer Storage and Recovery []Salinity Barrier FROM I TO I MATERIAL I I EMPLACEMENT MEMOD
Aquifer Test E)Stornrwater Drainage n•
Experimental Technology OSubsidence Control % ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets dnecessa
Geoth-alsHeatingic-tang Return) Other(explain under#21 Remarks) FROM 70 DFscemrlox mbt;tuNaess-Wreck tyM grain etc
4.Date Well(s)Completed::: 2-?- Well ID#:t S 11 1.77 rS7 fL 0 n- W ,s Q (fie
Sa.Well Location: IL S .1L
Facili / r Name F 1D# ff licable
may.. .c.�rP. ... .>. "'... . � . ct. ,. '.4 9 . .
7�{ 13� 1�a�►r el �i Dk-P'y\d A& �7 s(,s- . & 'L
Physical Address.City.and Zip IL 8.
�Q h V l A2L REMARKS uJfl I
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)mPermanent or Temporary Signature ofCcrtffied Well Contractor Date
By signing this form,I hereby certify that the weB(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthrs 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,onl 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
driUed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different fexpmple-3(a 200'and 2®100) construction to the following:
10.Static water level below top of casing: 3 D (fL) Division of Water Resources,Information Processing Unit,
If waer,level is above casing,use"+' 1.617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to send' 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: 011 (Z 0 T)4 construction to the following:
( e.anger rotary;cable,direct push,etc.1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEi.i c ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636.
i
13a.Yield(gpm) Method of test: I 24c.For Water'S ly&Injection Wells In addition to sending the form to
the address(es) above, also submit f one copy of this form within 30 days of
13b.Disinfection type: D C r i t,-', Amount: ':9 0 Z- completion of well construction to the county health department of the county
where constructed.
/°1 Form GW-1 North Carolina Dwartmem ofFavironmeatal Quality-Division of Water Resources Revised 2-22 2016