GW1-2022-03877_Well Construction - GW1_20220406

- ,Ir,l ll It 1 WI11:1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
F14.WATER ZONES
Well Contractor Name FROM TO DESCRIMON
it. 33 ft.
It. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER"(if ap licable
) Well
,P`r f� .l' ''} FROM TO DIAMETER THIC MATERIAL
�I'tQJ6d�l0 t'tl 8J l ft. ft in. yU
Company Name
3� 0 6 16:INNER GASING'OR TIJBiNG 'eothermal cl ed-loo
2.Well Construction Permit#: O FROM TO DIAMETER THICIGWSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) It. It. m.
3.Well Use(check well use): it fL in.
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �=al
al/Public
1/ fL;.,
L ` 33 ft AV in
Geothermal(Heating/Cooling Supply) Water Supply(single) ft R in
Industrial/Commercial Residential Water Supply(shared)
'1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
_J Monitoring Recovery ft. - ft.
Injection Well:
ft ft. ,
_ Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK: a lieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage It. R
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addition al sheets if necessa
Geothermal(Heating/Cooting Return) _,i Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes sea/rock type,w2in size,etc.
6 ft 5 &
4.Date Well(s)Completed:63125 ci`i Well ID# ft. l V R r a tl/ d $r✓
5a.Well Location: 0 ft Z .' : F
n 2 3 It. 3.j fL <
/C�n&l B r,.s�d w Cauasr S�� In�•�C
Facility/Owner Name Facility 1D#(if applicable) ft. ft
7 l_ Q o ft ft
(p ( 1�clt/Vt n'►''t i� Alt T I'1'rtl�
PhTC
Address,City,and ip //^�� ft
Sa�I Q 5-09'V 2-D 2 y 21.REMARKS -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � ,,DWI
�,
(if well field,one lat/long is sufficient) 22.Certification: :ct m�i l lUly RR &,
qn-r N 73' W 6-,� 4, 63 zs 9S
6.Is(are)the well(s)dIPermanent or OTemporary Signature of Certified Well Contractor Date
� By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or Psi<o with 15A NCAC 01C.0100 or 1 SA NCAC 02C.0200 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 tojthe well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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(GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages if necessary.
drilled:
z SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (fL) 24a. For All Wells: Submit'this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"J 1617 Mail Service Center,Raleigh,NC 27699-1617
£ t�
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
p l 12.Well constriction method: above,also submit one copy of this form within 30 days of completion of well
I��l°r` /'1•�
(i.e.auger,rotary,cable,direct push,etc.) construdtion to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i '
13a.Yield(gpm) Method of test: 141 P 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: 14714 Amount: OZ completion of well construction to the county health'department of the county