GW1-2022-03522_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ('Gee, Vfr/)ram 14,WATER ZONES
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FROM TO DI:SCRIPTION
Well Contractor Name 3L ft. /� O ft• a Jr�.,C C/ru f s
3 g 7 6 f{ 1 ft. _f n.
NC Well Contractor Certification Numher 15.OUTER CASING for multi-eased+yells OR LINER if a licable
FROM TO DIAMETER TIIICKNE s' I MATERIAL
Company Name Ib.INNERCASINGORTUBING eothermaldmedloo
M U 3O l�7s FROM Ttr DIAMF.I'EK THICKNESS MATERIAI.
2.Well Construction Permit#: ft, S ft. in,
list all applicable well emurnrr•tion permits(i.e.Ul('.Counnt State.I arimrce,Or.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM Tb DIAMETER SLOT SIZE THICKNESS dtATFR1AL
Agricultural 0MunicipalIPUblic Z 5 ft. L 0 ft. in. p/p Sc h Y a t irk
Geolhermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. i"•
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
FROM TO - MATERIAL EMPLACEMENT METIIOD @ AMOUNF
Irrigation ft. 3 ft.
Non-Water Supply Well: -�.r..Lr(fe `� r
Monitoring
Rccovery 3 ft. ft. �e H �e M t
Injection Well: / 0. 2"C ft. ib - -j U
Aquifer Recharge [3Groundwater Rcmediation 19.SAND/GRAVEL PACK i a Ilcable
Aquifer Storage and Recovery oSaliniry Barrier •FROM To MArERUL t;MPLAeI:MENr atenlon
Aquifer Test
Stonnwater Drainage G Z,�fL p ft. a N q ;
Experimental Technology Subsidence Control ft. rt.
Geothermal(Closed IAiop) Tracer 20.DRILLING LUG sit ch additional sheets If necessa
FROM TO DF.SCRIP'1•ION mina hardnnt snlFmck t• e. min 41le etc.
Geothermal(lieating/Cuoli"n'gg Return) Other(ex lain tinder 021 Rcmarks) 0 ft. ft.
4.Date Well(s)Completed:2 / -2-1—Well ID# / Y W—�� fr• Z fL �.`,- ��✓�
So.Well Location: Z•" ft- 3S" ft. 0 w', �• 'C S'd��y,�s /1
+/Y u 1 r t Q/V t �l �tl�utr vn�t fL O rt.
haciloy/Owner Narne Facility I Dh(if appl icable)
_ ft:
ft.
Z` 0 /&.yloesV,lIC'14rtu� Sd�f�.,y:/fie NC ��b� e. D. 9
Physical Address,City.and Zip
21.REMARKS
7r eat
Cmmty Parcel Identification No.(PIN) yi- F�_•,; •!1\1
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t•:^.
(if well field,one latilong is sufficient) 22.Certification:
ignature n(CenitieJ R`ell Com Hate
6.Is(nre)the wells)ffPernument or OTemporary
By signing this lnrm. I herehr certi(v tha1,0W u•ews)wax/were)mas'avr ted in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C'.011)n rn•/S.a NCAC 0C.n200 n'ell Consm,rtiea Siamlard,and that a
!/rlu:c it a relia+r,fill otet known well cunstrnrtiun i+tlirrmorion and explain the naave ul?hi•
ropy al'rhi,c record has been provider)to dir well rrw•ner.
repair raider&21 remarks s'ecrmir or on the hack 4thic fi,rrt. 23.Site diagram or additional well details:
You may use the hack of this page it,provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also altach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface. j 10 (ft.) 24a. For AW Wells: Submit this torn within 30 days of completion of well
Vor multiple well.,-fist all depth.,it dilTrrr•nI 1,wmp11-36d.T00'and Na,1/i01 construction to the following:
L
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit.
1617 Mail Service Center.Raleigh,NC 27694-1617
1f water level is aborr rasing.use
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the lbnn to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: O construction to the following:
(re.auger.rotary.cable.direct Push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(Rpm) Method of test 24c.For Water Supply R Injection Wells: In addition to sendine the Coen+to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type Amount: completion of well construction Ici the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of water Rcsourccs, Revised 2.22.2016
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