GW1-2022-04341_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
L Well Con ctor Information: �^a
Cf i/ O 14.WATER ZONES
Well eoutzoe rNaure APR 1 FROM TO DEs ox
n: tw
�D17 1-4 go
NC well Contractor CestifieationNamba Y ; r r 1� IS m
Al
'L' 3fi'OUTERCMWG =ul&cased FROM To DIAMETER! Tffit MATERIAL
f1. 1t. in
CompenyNam l� 5�38
16.IPiLVER CASING:OR TUBING' thermal closedianni
2.Well Construction Permit#: FROM I To I DWdETER ITHIQtNF3S MATERIAL
List all applicable well construction permits(r.e.UIC,Cormty,State,Vanfance,eta) & & hL
3.Well Use(check well use): fL & In.
Water Supply Well: 17-SCREErt
FROM TO DIAMETER SLOTSM TTDC[QffS4 MATERIAL
Agricultural 13MunicipaUPablic ft, n 11
Geothermal(Heati*Cooling Supply) We idential water supply(single) n n lu.
Industrial/Commercial DResidential Water Supply(shared) L GROUT
On FROM TO MATERIAL EMt�LACE6lENT METHOD&AMOIINT
clan-Water �n. 0
Monitoring ORwovery %
Injection Well:
tt. n
EGeo&mal
Recharge Groundwater Remediation FROM TO MATERIAL
Storage and Recovery DSalmttyBarrier FRToEtt�LACEMENTMETHOD
Test 13Stonnwater Drainage fL fLental Technology Subsidence Control n. fL
mal(Closed Laop) OTracer 20.DRILLING LDG aa eatin Coolie Return Other lain under#21 Remarks I FROM TO DESCRWIXON color =91rock imwainsize.etc
& &
4.Date Wells)Completed:l'/0-0e Well ID# 6�n- n- rLi e v !tL
Sa.Well Location: ft. ft.
/�
m4 �mc 11,Uk n IL
N Facility MM(ifapplicable) ft. ft.
711voew-'e-r
vH fiv lP{¢ f 1c 4O.Sc on /� iti n.
Physical Address,CitN and Zip �r_00 IL it.
q
C-noty, .Parcel Identification No.(Pi o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
(if well field,one Wong is sufficient) 22.Certific on:
ent or E)Temporary signatmte of Certified wen Cofactor
6.Is(are)the well(s)�rman Date
By signing dus form,I hereby certify that the wells)was(were)coutructed in accordance
7.Is this a repair to an existing well: [3Yes or v0 with 15A NCAC 01C.0100 or I5A NCAC�01C.0100 weA Construcfion Standards and that o
If this is a repair,fill out kamm well construction information and esplain the nature ofthe copy ofthis record has been provided to tine 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 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:For multiple we ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
wefts list ail depths rfdffererrt(emmple-3Q200'and construction to the following.
10.Static water level below top of casing: o UP Division of Water Resources,Information Processing Unit,
If"cotes level is above casing,use a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.8orehole diameter: �_(in.) 24b.For Iniection Wets: In addition to sending the form to the address in 24a
12.Well constructionmethod:
,�y above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,Able,direct posh,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'll 24c.For Water 3unnbr&InawAo Well . In addition to sending the form to
the addres(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: •VZ completion of well construction to tite I county health department of the county
where constructed.
Form Gw-1 North Carolina Depamnent ofEnvironmental Quality-Division of water Resources Revised Z 22 2016