GW1-2022-04022_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
17 }GQi /�OtJ�^S 14.WATER ZONES
Well Contra tor( /�Name FROM TO DESCRIPTION
�S v 6 /T ft. ,a ft.
ft.
NC Well Contractor certification Number 15:OUTER CASING:formniti'. sed:wel►s OR LINER ifii`licafile
6r�y M J c `l JQ�� q m e r FROM TO DIAMETER THICKNESS MATERIAL
1 I W i—(---1, in. -v L
Company Nam
16.INNEiLCA$1NGOItTUBING.(eothermafclosed46o
2.Well Construction Permit#: `�� 01004 — a0 a' FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.VIC,CounJ),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) fL ft. in.
industrial/Commercial Residential Water Supply(shared) 18.'GROUT
Irl'i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o ft. 6Q11 /?'l d t
Monitoring QRecovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge QGroundwater Rernediation
19:SAND/
Aquifer Storage and Recovery DSalinity Barrier FROM GRAVEL PACK.(if alivable)TO MATERIAL. EM1n'L.ACEM1iF.NT METHOD
Test [DStormwater Drainage ft ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothemlal(Heating/Cooling Return) Other(ex lain under#21 Remarks) FROM To DESCRTMON color,hardness seiVrock a ram sim etc.
0 ft. ['lj ft. Gla
4.Date Well(s)Completed: 3 .� 4 X Well ID# 5o ft. •q 96J ft- �� G
Sa.Well Location: ft. ft.
�ath�lC�ir lnQS ft. ft.
Facility/Owner Name
LiJIFa�ci lityl/Dt/O(i fappI licoaablle) ift.. ft.P
Physical Address,City,and Zip e� 1 REMARKS:
ft.
W a Kc ! o o�aJF�.D$0 21, MARKS:.
County Parcel Identification No.(PIN)
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W �LZ✓'% Z Z Z.
6.Is(are)the well(s)dPermanent or DTemporary Sign re of C rifled Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)coutructed in accordance
7.Is this a repair to an existing well: QYes or EK4 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iflhis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dulled. 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V"" (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if doerent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
(j. �y 4 above, also submit one copy of this form within 30 days of completion of well
_ r6 !(i.e.auger,rotary,cable,direct push,etc.) construction to the following: '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: I� 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: k4-� Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016