GW1-2022-03524_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.well Contractor Information:
/ I!,(/✓1�l.V I n fJ Cr � ✓ cG C' �riuJ 14,WATER ZONES I
G
FROM TO DESCRIPTION[
Well Contractor Name ft. ft. 3� re r,fl rb�u.GQ ri)L�
S'7G A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased well's'OR LiNER if a livable
FROM TO DIAMETER THICKNESS MATERIAL:
in
Company Name 16.:iNNER CASING OR TUBING eothermal cl its eda00
V" O 3 O '!?s FROM TO DIAMF.TISR THICKNESS MATERIAL.
2.Well Construction Permit#: ,'/ «. fL in,
List all al>rdicnhle uz•1l cunsuvetion permits ox. Uh.:(-Doom.State,Variance.vil '.
ft. ft. in.
3.Well Use(check well use):
17:SCREEN
Water Supply Well: FROM TO DIAMFTF.R SLOT SIZE THICKNESS MA
Agricultural F,.rTERIAL
- Municipal/Public ft.
Geothermal(Heating%Cooling Supply) [)Residential Water Supply(single) ft. fL in.
Industrial/Commercial oResidential water Supply(shared) 18.GROUT
FROM T'O MA7F.RL\I. EMPLAC6M F.IN'f\1FTHOD&AMODtiT
Irrigation ft. ft. eot� r n
Non-Water Supply Well:0.
t
Monitoring [)Recovery ft. n.
Injection Well:
Aquifer Recharge [)Groundwater Remediation 19.SANDIGRA L PACK Ira Iicable
Aquifer Storage and Recovery Salinity Barrier
FROM TO - MATERIAL. '- EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage
«. fr.
Fxperimentall'echnology
Subsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer 10.DRILLING LOG attach additional sheets it ntxesse
FROM TO DESCRIPTION(color,hardness,mill"..t e, min sin.etc.
Geothermal(Hearin Conlin Return) Other(explain under H2l Remarks) 0 ft. 6 tt. Rem rp wnQ G
4,hate Will Completed: /�- L Well 1p# W D ill «. s fr. Q r.� 4- C/ a K.�p
l(s)
zS ft. 3 it. rvc✓,✓c/ e-llll
Sa.Well Location:
� n. y o n. ra I-fug .te,i,S1..
n(a f'r;e,v �q ,solv�'o�J�
Frcilin°tOwner Namc Facility IDrf(it applicable)
i
3z�y !ay`or1y;/le flfvy,:ffofrrd,//eAle' 2$'6 ft. ft.77 ft. -
Physical Address,City.and Zip
21rREMARKS
t�r I d e-11 or d G ;/l�d w ' ?9
Parcel Identification No.(PIN)
f�unq' ✓` I� �GN+%C
rV J�//lCi
5b.Latitude and.tongitude in degrees/minuteslseconds or decimal degrees: raM To
iil,well field•one fat'Iong is sufficient) 22.Certification: d r� l
Signature nfCenified Well Contracdpe�' Date
6.Is(are)the w'cll(s) Permancnt or �(Tcmporarp
Hv,icnine this(urnr,!hvrth, rvrtdy that the milts)xns(,,,err)trl in arrtirtt<mcr
7.Is this a repair to an existing well: [)Yes or o pith 15.4 roc 02C.olnn n 15A \CA('lax .n Oo 14'cl/Cn+nnvrtrnrr Srurr.11 and than a
!/7Gt,is D repnlr,l}Il our knuo•n wellennetrneriun in/�rrmariar trod explain alit nnhu'e of the
t opt Dr this ret ord has liven provider!tt the wt ll r„ner.
rJntu•order•all renmrkc section nr on the hock of this p,rm' 23.Site diagram or additional well(details:
1'ou may use the back of this page to provide additional well site details or weil
X.For Greoprobil 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: SUBMI -TAL INSTRUCTIONS
9.Total well depth below land surface: / t7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
corm dwells fist all depths ifdiffirnt ml1'and 2([ti1001 construction to the following:
10.Static water level below top of casing: 33 (ft.) Division of Water Resources.Information Processing Unit.
it.eater iewl is trfxne main!;,ruse" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the fimn it)the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 5�,,,, �' construction to the following:
Ii.e.auger,rotary,cable,direct push,etc.i
Division of Water Resources,U�derground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scn'ice Ccntcr.Raleigh.NC 27699-1636
Method
of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
I1n.Yield(gpm) the address(es) above, also submn one copy of this tome within 30 days of
Amount: completion of well construction to the county health department of the county
131r.Disinfection type: where constructed.
Rcvtscd 2-22-2016
North Carolina Department of f n mnt cironcal Quality-Division of-w'atcr Resources
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