GW1-2022-03136_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J1i
Fri e- 54l4 e`o✓l M.WArTER ZONES
FROM TO DFSCRUMON
Well Contractor Name
�'78�- 1� s fL 3a ft.
IL ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cascd`wells ORLINER`if a' licahle
FROM TO DIAMETER THICKNESS MATERIAL
Company Name D fL -�rr fL /y in. y y0 1 L C
16 INNER CASING OR TUBING `eothermal dosed-loop)
2.Well Construction Permit#: to o( J / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OM cipaLPublic ft ft. n.
Geothermal(Heating/CoolingSu 1 esidential Water Supply(single) 3 Al �2 �� 0 PUe
Supply) PP Y( g ) ft, ft in.
Industrial)Commercial .. [)Residential Water Supply(shared)..
18.'GROUT
_ Irrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL 2-0 ft. SAX&,- l 6 `t(/ p.-r
Monitoring Recovery ft. ft.
Injection Well:
em
ft. fL
Aquifer Recharge [3Groundwater Remediation
19.'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage fL ft
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) Tracer 204 DRILLING LOG fattach additional sheets foe esg$';
_ !Geothermal(Heating/Cooling Return) _ Other explain under#21 Remarks) FROM TO DESCRIPTION e/611or. I-'SoiUrock n etc
U rL to ft. C/q, �r
4.Date Well(s)Completed: ot7 2.2 Well ID# 10 f Zd fL S C f ti ' e�ois
5a.Well Location: ;?C1 iL Z 5 fL ar 4 S'(t
Aar&A ljae2 Del Alnae/ 25 IL 30 ft-
Facility/Owner Name Facility lD#(if applicable) fL ft.
Vok,na nr k14M Lo'tOf) 1S3TOO fL ft.
Physical A s,City,and Zip // / ft. ft. 0 ,r _.
RSDI 1C�owlo�6aZl:7 2L�REMARKS
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) q 22.Certification: :'T lhViLY11 RJiI rl'�lrF=
OA— OZ 2y 2 2
6.Is(are)the wells) ermanent or OTemporary Signature of Certffied Weil ontractor Date
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: E)Yes or _ To with 15.4 NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information 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 of thus 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
constriction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2®100') construction to the following: I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6- (in.) I J 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r 1'Ilad above,also submit one copy of ibis form within 30 days of completion of well
12.Well construction method: 11' construction 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 ServicellCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: i"h"' 24c.For Water Supvty&Iniection 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: 14714 14 Amount: 02 completion of well construction Ito the county health department of the county