GW1-2022-04858_Well Construction - GW1_20220520

1..Well Contractor Information:
/ Z' N fl, t,irl - 1V 4 14.WATER ZONES !
WellContra r Name j FROM TO DFSCREMON
We
t� C
2( 2t- IL
fL ft.
NC Well Connector Certification Numbs 15.OUTER CASING for mtrEtle'ased wells OR LINER a cable
FROM TO DfAMEIER TffiCtINFSS MATERL\[
4-- -4q ft ft. in.
Company Name
16.INNER CASING OR T[JBIING(geothermal closed-ioo
2.WeU Construction Permit#: AV 5 aZ V Z:;L"' 1-0 V 7 EMM To I DtAMSrER I THICKNESS MATEMAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,ere.) Q ft.- Zl ft. tf in.
3.Well Use(checkwell use): n' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DL"WrER SLOTSITE TRICKINESS I MATSRrwL
Agricultural E3Municipal/Public Z( ft. 2.4f ft. in.
Geothermal(Heating/Cooling Supply) YP Sidential Water Supply(single) ft; p, la
fndustrialiCommercial [DRe;idential Water Supply(shared)
lti.GROUT
"JErrigation FROM TO MATERIAL E1iPLACEMIM METHOD&AMOUNT
Non-Water Supply Well: 20 ft, zf ft.
Monitoring DRecovery O ft. zo ft. Pa .•.l. poa�
_A
Injection Well:
-- :F �S-
rRec ElGroimdwate,Remediation- ft. R — — --
tie••
19.SAND/GRAVES.PACK a Ucable
Aquifer Storage and Recovery E)Salinity Basler FROM TO MA7EML I EMPLACEMENT METROD
Aquifer Test . [3 Stormwater Drainage ^ZO fL Z IL ft- #.3go'.-Cp perm
Experimental Technology []Subsidence Control % ft.
Geothermal(Closed-Loop) 13Tracer •20.DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) 00ther lain under#21 Renuuics). FROM To DERMUP ON color,bardneM sallfmcktypN gein she,tte,)
o� o fL ft.4�
4:Date Well(s)Completed: 9 Lf Well ID# fL A-W R' t.
Sa.Well Location: ft. 7 ft. C$e 5owJ
v D✓Ilf �71Mi'YJ'P.+��/IZ - fa re. .
Facili Name Facility MH(ifapplieable) R' n'
�rvhl/e ft. ft
ft. ft. a vp¢"a N p1-,- --1
Ph i Address,City,and Zip �
V �-H- y -1
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minnteslsecoads or decimal degrees:
(jfweU field,one lat4ong is sufficient) 2L Certifications
N �-
O W-V
6.Is(are)the well(s)�ermanent or Temporary Signaa ofCartified Well Contractor Date
` By signing this form,I hereby cero that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or SKI with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards sad that a
Ifthlr Is a repal,ftf'out known well cow&wlion lnformatlot.and Psplain the nature of eh ., copy of this record has been provided to the well owner.
repair under 1121{emark section or on the back of this form
23:Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Well;having the same You may use the back of this page to Provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SIMMI2TAL INST$UCTIONS'
9.Total well depth below land surface: ZQ' (ft-)_ 24a. For All Wells r Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a 200'and 2@1001 scion to the following:
10.Static water level below top of easing: !�Cr+t arc 3 AN• Division of WaterResonrces,Information Processing Unit,
lfvmw level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: aftAgY G, (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 • . above,also submit one copy of this form within 30 days of completion of well
wa 12.Well construction method: ft we 61 V%-,.1 d � construction to the following.
(Le.auger,rotary,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
132.Yield(gpm) 1 O Method oftest: 24c.For Water Sunnly&Infection 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: Weil Amount:'~`Soo . 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