GW1-2022-01944_Well Construction - GW1_20220224

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DFSCPMMON
WeU ContractorNatne �
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NC Well Contractor Certification Numberbpa�j Pool k ;
l LrA Cv1FROM TO DIAMETERTHICKNESS MATRPML
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Company Name �+
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2.Well
F Construction Permit#: !� I KJ �M I TO DIAMETER I 'r>ncta+tass � MATERIAL
List all applicable well construction permits(Le.UDC,Cbsmo;Slate,Variance,etc,) ft• in
3.Well Use(check well use): ft. % tn.
Water Sa Well: f..... .... �,.. •- ... .,. � � . .. .,. ���,
ly FROM TOI DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public ft, ft. I in t
OGeothermal(Heating/cooling Supply) tResidential Water Supply(single) ft. it. In.
❑Industriamommerciel ❑Residential Water Supply(shared)
131niotion ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL Q fL6CA Q A" i
❑Monitoring ❑Recov % t=. q Infection Well: ft. f❑Aquifer Recharge ❑Groundwater Remediation
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMiLACEMENTAILr11101)
❑Aquifer Test ❑Stormwater Drainage fL It.
❑Experimental Technology ❑Subsidence Control rt %
Meothermal(Closed Loop) ❑Tracer - L
M.
Ocroothennal eatin Coolin Return ❑Other(e lain under#21 Remarks FROM TO DEseRIFTTON color bordoes wlVreck O eta
4.Date Well(a)Completed:j Well ID# tt. f4. PIP ja!t
5a.Well Location: o 0 k
b ft. rt.
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-Fact 1,. :. :Name Facility IDN(if applicable) ft• R• '
G 'I-e fQ C, ft. ft. F
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Physical Address,City,and Zip
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TIN : .
1�l i�liri P}t� ..v�
��h Parcel.Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W
6.Is(are)the weII(s): []Permanent or ❑Temporary
Signature of C ed Well Contractor Date
f By signing this form,l hereby certift that the wells)was(were)const—ted in accordance with
7.Is this a repair to an exisdug well: Oyes or i'!No 1 SA NCAC 02C.0100 or 15A NCAC 02C 10200 Well Construction Standards and that a copy
If this is a repair,fill oat known well construction information and explain tyre nature of the 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells (add O'er in Remarks Box).You may also attach additional pages if necessary.
drilled: l - U.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15® (R-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (f�) Information Processing Unit,1617 MSG,Raleigb,NC 27699-1617
tfrmter level is above casing,use"+" t
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: y Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:� lr® �r; - 24c.For Water Sa and en-Loo Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental department of ft county where Installed
FOR WATER SUPPLY WELLS ONLY: L 24d.For Water Wells rodacin over 100.000 GPI):Copy to DWR,CCPCUA
U 4 O U) Pernttt Program,1611 MSC, et ,NC 27 99-1 11
13a.yield(pm) Method of test `
13b.Disinfection type: Amount:
..,, to o,rs rim nenertment of Environmental Oualitv-Division of Water Resources Revised 6.6-2018