GW1-2022-03589_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�— FROM IIIDESCRIPITON
Well Contractor Name ft. It.
L-IY Z .�- ft. ft
NC_Well Contractor Certification Number I 15.•OUTERCASING'[ormttltl-cssedvells.ORLaTER a' )Ii
FROM` TO DIAMU"Awk Tm___ �/&
• It. 116C/
G v �
Company Name f 16:INNER CASING O1tTUBING eotl ermat eldsed 1ao =.
t7 �►4662 3 FROM TO DIA1ttETER THICKNESS v MATERIAL f
2.Well Construction Permit#: ft. % in.
List all applicable well construction petnuts(ii.e.UIC,Count},State,Variance,etc.)
ft. ft. in.
3.Well Use(cheek well use):
FROM
FR
Water Supply Well: To DIAMETER ,SLOT slzE` THICKNESS MATERIAL
❑Agricultural ❑Monicipal/Public �, ft to a
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL In.
❑Industrial/Commercial ❑Residential Water Supply(shy) 1s GRODT
FROM TO MATERIAL EltiPr.ACEDfENT OD&AMOUNT _
0—Irrigation []Wells>100,000 GPD fL ,
Non-Water Supply Well:
❑Monitoring ❑Recovery ft tt
Injection Well: ft• %
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVELPACK a table
❑$allIIt Barrier
FROM TO MATERIAL EASPLA QD
❑Aquifer Storage and Recovery tY 1 CC
❑Aquifer Test ❑StormwaterDrainage R �� ~' e
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geptile[ma1(Closed Loop) ❑Tracer 20 DRMLING LOG attach additionaI" eets ifinices
under#21 Remarks) FRO rd
M TO DESCRIMON colo,haness,sowrock a c-
❑Geothermal(Heating(Cooling Return) ❑Other(explainft. fL
4.Date Well(s)Completed: v ft ft
��Well ID#
fL fL
yell Location:
ft.
Facility/Owner ame Facility ID#(if applicable)
ft. ft
Yhyst Ad��rrsss t and Zip -• _"
�> '� 21i REMARKS... -
C1G
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 2 . catio
,t Certified Well CQ actor
6.Is(are)the well(s): tKPermanent or ❑Temporary
` fining thisform,I hereby certb that the well(s)it-as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jlll out known well construction information and explain the nature of the
of this record has been provided to the well oivner
repair under 021 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'Se:e Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-I is needed Indicate TOTAL NUMBER of wells
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C/o (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wd&list all depths if different(example-3(d,200'and 2@100)
�)�t 24a. For All Wells: Original form to Division of Water Resources (DWR),
(fL)10.Static water level below top of casing: J Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
I/ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (• )f program,1636 MSC,Raleigh,NC 27699-1636
12.Well Construction method: / O For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) NCO ty environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100,000 GPD:Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) j�d� Method of test:
j/� /-i
t^.r, ;3ititt€ctzen ttte: I�[ u -- —