GW1-2022-03451_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
M 1 tau S
/ Well Contractor Name FROM TO DESCRIPTION
'' ft ft
.J'AA V L(Ai, qo<-A & ft.
NC Well Contractor Certification Number
r NOU ZRCASINO (or.;n;uld.cased wells 01t':ZINER
(:arcade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
_ ft. ft in.
Company Name 16r11VIHFRCASINGO1
€ .1
"'therwalolosed loo
2,.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,County,Slate,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
FROM TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL l
(Agricultural Municipal/Public 0 It. fa in.
(Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in
(Industrial/Commercial Residential Water Supply(shared) 1g.CROIIT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
(Monitoring 13Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
[Aquifer Test ®Stormwater Drainage ft ft
Experimental Technology E3Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20 D1tI1 LIlVG":liOC atta6h.`addrtionil.'sheetsi[isecessa
TO
'Geothermal(Heating/Cooling Return) FROM Other(explain under#21 Remarks) fa ft DESCRIPTION(color,hardness soittrock tyM gmin sue etc.
4.Date Well(s)Completed: �' Well ID# ��r'fd ft ft
5a.Well Location: ft ft
( ft ft
Facility/Owner Name Facility ID#(ifapplicable) & ft `
'Wo 11, is Z nip Let ld . Am ft. ft AR 2 2 2
Physical Address,City,and Zip
IL ft.
II�MnA Wt-t
County Parcel Identification No.(PIN) 't t
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/Iong is sufficient) 22.Certification: NCKIC t-(52S fi
N W r-10�
.�' .1.2'isla
6.Is(are)the well(s)13Permanent or OTemporary Signature ofCe 5ed Well Contractor 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: 13Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!f this 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 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,only 1 GW-I 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: ( (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
i%or multiple wells list all depths ifdiifferent(example-3 a@2010'and 2@100') construction to the following: -
10.Static water level below top of casing: 7'(vt (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
tr E.
11.Borehole diameter: �o (in.) 24b.For Infection Wells: In addition to sending 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: -son;e. construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
j FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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: Amount: completion of well construction to the county health department of the county
where constructed.
1,
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016