GW1-2022-04451_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
-�'
�s�p�;l�V 7 zZ
14.WATER ZONES i
Well Contractor NameA FROM TO DESCRIPTION
`l-ft. 7 ft, j(�... t/1'C/ '7'(�n le
NC Well Contractor Certification Number /� 15.OUTER CASING for multi-cased welts OR LINER ii1a livable
_JWM,�L /w,.L` t 1ell/1n/I'rrl_A l r FROM ft 'to
f ft DIAMETER to THICKNESS MATERIAL
Company Name cFT'QV (/V L/ l7 �/(�(1 '^ /_D /+N, �•
16.INNER CASING OR"Tl)BING(geothermal dosed-loop)
2.Well Construction Permit#• /l � FROM TO I DIAMETER THICKNESS MATERIAL
l.isi all applic•ahle•well conslnrction pernrir l rl(',CounlY•.\talc. I briance.ew ft. ft. in.
3.Well Use(check well use): in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in,
Industrial/Commercial D Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. �1 ., ft. /f�
Monitoring Recovery ft. of ft.
Injection Well:
ft.
Aquifer Recharge Groundwater Remediation ft.
19.SANDIGRAVEL PACK ifa licable
Aquifer Storage and Recovery OSal inity.Barrier LFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ` [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft,
tt.
i
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary
FROMTO DESCRIP ON(color,hardness,soil/rock t e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) ft. w ft.
4.Date Well(s)Completed: 31a Well ID# ft. fr. 41,rh 50
ft. ft. � t.✓
5a.Well Location:
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
't L + e 3'7 Treti Ala-•e]Dr twos e &/C ft. ft. y
Physical Address,City,and'Lip ft. ft
j 21.REMARKS
County Parcel Identification No.(PIN)
tiNi ''�N^• _
Sb.Latitude and longitude in degrees/minutes seconds or decimal degrees: pIr 9 3 I
(;fwcll field,one lat/long is sufficient) 22.Certification: �y N
6.ls(are)the well(s) Permanent or Temporary SiZIre of enilied I Con(ac r Da
41 :n,�thr.c/orn. i here•h.c •Idi'drat the we•IlGr)tress(trerel c onsirucled in acc ewileowe
7.Is this a repair to an existing well: OYes or [RNo with ! :I r1CA( 02U.0100 ur/'A?d(.4('(I=('.11?llll ti'e//('unc/rnctinn,Gunn/ruz/c cur ihar o
//!his is ei repulr.Jill um knmrrl u e/I eunsiruction in(,rnrariuu and explain the nunrre u/lire er yn of;,his recur,/hu.s hee•n provided to the well owner.
.bole render 1/re•murks.ec•ctir»r w nn the buck u(rhi.+,Jbrnr.
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 details. You may also:attach additional pages if necessary.
construction,only I GW'-I is needed. Indicate TOTAL NUMBER of wells
drilled: I SUBMIT'fAl,INSTRUCTIONS
9.Total well depth below land surface: �v (ft-) 24a• For All Wells: Submit this form within 30 days of completion of well
h; ,nrdrp/e we/n her au depth.,(J dl(fc rear(e.rainple-3rfi200 and 2rit)l 0') construction to the following:
10.Static water level below top of casino: (ft.) Division of Water Resources,Information Processing Unit,
t/+outer level Is abort casing;.use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: k o (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24,1
above. also submit one copy of this firm within 30 days of completion of v%ell
12.Well construction method: R 074r11/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of'Water Resources,indergruuud Injection Control Program,
r,3.
R WATER SUPPLY WELLS
,/ONLY: , 1636 111ai1 Service(-:enter,Raleigh,NC 27699-I636
.field(gpm) 6 tr r•r Method of test:.�vW 24c. For Water Sunul & Infection Wells: In addition to sending the lorm to
the address(esl above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_ l6 0- completion of well construction to the county health department of the county
where construcied.
Form GW-1 North Carolina Department of E!•6ronmenial Quality-Division of Water Resources Revised 2-22-2616