GW1-2022-03523_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD(GW-1) For httcmal Use Only:
I.Well Contractor information:
14.WATER ZONES
1,Aj i i l U M Cr l y
FROM TO DESCRIPTION' /�
Well C nafactor Name Sft. '5/ ft. Sd rO/�`' (- /
3,5°•7G A n. H. j
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER IF a lieable)
FROM 1'0 DL\MF.TF.R THICKNESS MATF.RLU.
ft. n. in.
Company Name 16;INNER CASING OR TUBING eothermsl closed-loo
FROM TO DIAMI:TF.R 1'lI1CKNF,S.e MATERIAL
2.Well Construction Permit k: , It. in SG� 0 t/C-
List anappfit•ahle•trel!can.rtrvction permies(U.,UIC;Caungt State,Variance.etc.) 0 n
fl. Tt. in.
3.Well Use(check well use):
17.SCREEN
�4'ater Supply Well: mtoat TO DIAM1IETF.R SLOTSI7.E TIIICKNF.SS MA1TiRLU.
Muncpa 30 ft. ys ft. 1n 0�� S(k((O Y L
Agriculwnl � iilMublic s
Geothermal(llcating'Cooling Supply) Residential Water Supply(single) ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
FROM TO MA"I ERI\I. EMPLACEMENT MFTHOD 6 AMOUN7 Irrigation b ft. 3 ft. o 0 9—
NO -Water Supply Well: Doll rG.
Monitoring Recovery 3 2 /
Injection Nell: Z3 e, . w u
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a lieable
I:M1IPI,:\CEMENT\tI:TIIOD
Aquifer Storage and Recovery Salinity Barrier FRO%I TO MATERIAL
Aquifer Test [3Stonnwater Drainage
7 ft, ft.
o-' Subsidence Control h. ft.
Experimental Technology IJ
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additlonol sheets if necessa '
FROM TO DESCRIPTION t rotor,hardness,"Ivroek type.9min dre ete.
Geothermal ileatin Cooling Return) Othcr(explain under P21 Remarks) fl fl S tt. e�Q C f 61.
_ L rt• n. d+i �a C C �t:.v�
4.Date Well(s)Completed:2�! Z Welt I D# �" S
Sa.Well Location: 1 ft. 1J
NcJ G'N f/ �� t .,l raw.✓S !'ClrfrC A�rr� •s
n. ft.
Facility%Owner Name Q Facility IDt!(ifapplicahlel
Physical Address. ity.and 7ip IS �7
21.REMARKS
�KCounly Parcel Identification No.i PINT
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifwell field,one[at/long is sutTtcieni) 22.Certification:
N W trF t•'c1�l�er��t L `�
Signature of-Ceni led Well ContraG Date
6.Is(are)the wcll(s) _ Permanent or Temporary
Bi signing Certified
his Jute. /ell C r rrrtili•that thv nr(h.,l tray lu'vrel rarrstrnered m necnrr(nnrr
uidr I3.4 A'C4C 02C'.0100 w 15.4 NC•4C 02C 1I200 a cll c atm etion Standards and that a
7.Is this a repair to an existing well: Ol'es Of copy afthis record has bren provided to the+,ell m,ner.
II Phi,f,tt repair•fill nttt known well r•unstruetian btlb"nutir+n and explain the nature q the
repair ratdrr#:1 remurkc.section,rr an the hack of this frn•m. 23.Site diagram or additional well ldetails'.
You may use the back of this page to provide additional well site details or well
8..For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: _. r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) 249. For All Wells: Submit this tolrn within 3l) days of completion of well
Farr multiple wells list all deprhv ifelilk enr te.rermp/r•-?(ii'?011'nrrd'liGlO/l') construction Io the following:
III.Static water level below top of casing: 3 2, (ft.) Division of Water Resources.Information Processing Unit,
/l vu•+h red ie abort casing,aae"+ 1617 Mail Service Center.Raleigh,NC 27699-1617
n to the address in 24a
11.Borehole diameter: 6 (in.) 24b.For Inieclion Wells' In addition to sending the lim
above•also submit one copy o m f this fmm within 30 days of completion of well
12.Well construction method: construction to the following:
(i,e.auger.rotary,cable,direct Push,etc.I
Division of Water Resources,Underground Injection Control Program.
FOR\1'A'1'ER SUPPLY YELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
Method of test: 24c.For Water SDDDI\•K Injection Wells: In addition to scndinc the form to
13a.field(gpm) the address(es) above. also submit one copy of this form Within 39 days of
Amount: completion of well construction to the county health department of the county
13h.Disinfection type: where constructed.
Fort(iW-1 North Carolina Department of Gnvirumnental Quality•Division or water Resources
Revised 2-22-2016
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