GW1-2022-03526_Well Construction - GW1_20220322

Pr1nt Eorm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.% ell Contractor Information: /F �` J
6+xe d r� r'/'� 14.WATER 7A)NES
FROM TO DESCRIPTION
Well Contractor Name 33 it o ft. $e` Cd l4ea,—o f"(�{�✓f �-
:3 76�} ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wellsk OR LINER It a licable
0 FROMTO DIAMETER 1 THICKNESS MATERIAL
A. ft. hi,
Company Name O IC INNER CASING OR TUBING- eothermal eloseddlio
FROM TO DIAMF.TF.R ! THICKNESS MATERIAL
2.Well Construction Permit ll: p, ft. in.
Lisa all applicable u•vu cattra•urtiur,permits(i.e.111c,Count"'Stale.t'irrinnre,r¢'.)
ft. ft. in.
3,Well Use(check well use):
17.SCREEN dtATFRIAL
Water Supply Well: FRONT To DIAMETER SLOT SIZE THIC)l
Munici al/Public ft. D. in.
Agricultural � p'
Geothermal(I leafing/Cooling Supply) oRcsidential Water Supply(single) ft• rt. in.
Industrial/Commercial olkesidential Water Supply(shared) 18.GROUT'
FROM TO a1ATFNL\I. EMPLACEMENT MF.TIIOI)&AMOUNT
Irrigation O ft. [-/D ft. F.ti }— Tr e its, C SIP"r+
Non-Water Supply Well:
oniloring Recovery ft. n.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwalcr Reniediation 19.SAND/GRAVEL PACK If a licable
Aquifer Storage and Recovery ©(Salinity Uarrier FROM To atnTERtnt. Fntrt:,u:F:+IENT METHOD
Aquifer Test oStormwater Drainage
ft. ft.
Subsidence Control
Experimental Technology �•
Geothermal(Closed L. 1 Tracer 20.DRILLING LOG attach additional sheets fin eccasa
FROM TO DESCRIPTION color.hardnrsr,snlVrnck t r. rain si,r,etc.
Geothermal(i'lealin Cooling Return) Other(ex lain under N21 Remarks) tL fL O� G`
4.Date Wells)Completed: r o yti t
tt. G n• B f 7 AlaJ 4,,✓G� f%la
So.Well Location:
Q.,II//9q SoI 3 6 fi• n. S.
ft. fi.
F;tciloy`Owncr Name Facility IDN(if applicable)
All Z86 77 ft. rt.
Physical Address,City.anti Zip 21.REMARKS
�eGCG�( '3 ON uG �NSu tGiOw.t
COunn -n
parcel identification No.(PIN) r 1
a eoit CC -*-
till b tl lcl/f i'�M,C u
$h.Latitude and Jonglhlde in degrceslm[nuteslseconds nrdecimal degrees: rp-*e J-_rise.e t)o ti
tIf welt Geld.rate laillong is sufficient) 22.Certification: N a"%J
N �/
Signature of Centfied\4cll Cantrocwr
Date
6.Is(are) he well(s) Permanent or ffTcmporary
Nt•signie this fified l"I,C r rerliji thul it,ur•1/(.v)»'rA'lu'errl rrmslnrcred in arcurdruur
with 1.1.4 NCAC 02C.11 n,n m LSA vCAC 02C nznn Well G„trn•arrinr,Standards and that
it
7.Is this a repair to an existing well: Oyes or ONO copy nl rhir record h,ae been provided in the welt corner.
!1 this o a repair.fill nut known well rnrrsu'acrinn infnrrnutina and e.q,hiin the lati r uJ the
repair under 4 1 remarkr.e•etion or as the bark r)1 this form 23.Site diagram or additional well details:
You play use the buck of this page to provide additional well site details or well
8.For Geoprube/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:_, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (Il 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr m0twir wells list all depths i/'dilli'rent(eranq,le-30121)0' nd_'(fit,m(r) conslmictinn to the following:
10.Static water level below fop Of casing: (ftJ Division of Water Resources,Information Processing Unit.
It water Irma a alnna•rasing.u..- 1617 Mail Service CeiHer,Raleigh,NC 27699-1617
11.Borehole diameter: V (in•1 24h.For Iniection Wells: In addition to sending the form to the address in 24a
above.also submit one copy Of dlis'form within 30 days of completion of well
12.Well construction method: So�'L construction to the following:
I i.e.auger.rotary.cable,direct push,etc.)
Division of\►'afar Resources,Underground Injection Control Program.
=Disinfection
LI,S ONLY: 1636 Flail Service Center.Raleigh,NC 27699-1636
Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one COPY Of this form within 30 days of
Amount: completion of well construction to the county health department of the county
- where constructed.
Form GW-1 North Carolina Department of Environmental Quality-I)i,isinn of Water Resources
Rcciscd 2-22-2016