GW1-2022-03876_Well Construction - GW1_20220406

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WELL CONSTRUCTION RECORD (GW-1) C'rg For Internal Use Only:
1.Well Contractor Information:
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EEr ta c Ja 4e l5 -- 14 WATER ZONES `
Well Contractor Name FROM TO DESCRIPTION
j p h 33 ft. J 7 ft.
ft. M
NC Well Contractor Certification Number 15 OUTER CASING for mu -cased wells OR LINER if a licable
FROM T TER THICKNESS MATE RIAL�4fl�CkOnS WQ or�// j
Company Name O ft. 3 3 fL %/y in. 51W
y0 pile
7` 9 16.INNER CASINGORTUB ING eothermalclosed-loo"
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2.Well Construction Permit#: '1r2, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft fL tn.
3.Well Use(check well use): ft. ft. ( in.
Water Supply Well: 17.SCREEN
FROM TO DLIMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Vidc.
pal/Public , � ft. 3 ft. 1(� mi /2 SC� yb
)Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
18.'GROUT
_ lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 20 ft- jh �A_ //o to r
_J Monitoring []Recovery ft. ft.
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation 19,SAND/GRAVEL PACK If a i cable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:-)Aquifer Aquifer Test OStormwater Drainage ft. fL
Experimental Technology 0Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/—k type,gridn size etc
4.Date Well(s)Completed: Zy ZZ Well 1D# %J fc 26 R (,A!/ GAu ..
5a.Well Location: yt a It.
30 fL ' S4-d 61-
&jSeo C/„TOJaj?Ae� $ �UJ t n/ PO o�f tfa i"� � �
Facility/Owner Name Facility ID#(if applicable) ft. fL
�$36o fL ft
Physical Address,City,and ip 7 ft. ft.
1602 0l02367 ;21:REMARK5 .r %„
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR
(ifwell field,one lat/long is sufficient) q n L 22.Certificaationn-
3Y°7Q t Q ZS ° N 7/° 0 1. 7 W .ba`-LA `{ J" �
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L?-a 2 2
_ 6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or � with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ' (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100//') , construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" it 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 15 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
R��4r �H above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: !/�
(i.e.auger,rotary, construction to the following:
g Cary,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(gpm) D Method of test: Ln1a 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
13b.Disinfection type: i/�H Amount: D Z completion of well construction to the county health department of the county
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