GW1-2022-05010_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
n
1 ynf 1") 1 I\�1/� �\( 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
Sbrft. ft. y n
NC Well ontractor Cenificatio Number
C`� ° 15.OUTER CASING fm•multi-cased wells OR LINER(iC a licahlc
i 9 1 A v , +� FROM TO DIAMETER THICKNESS MATERIAL
V1/ l u ` \ \ 1 .r ft. �� ft. I a in. 5C JtLJC7 1 p
Company Name
r� 16.INNER CASING OR TUBING cotherm I closed-loop)
2.Well Construction Permit#: a ©0s1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell connsuvction permits ri.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:3 Agricultural Municipal/Public 5 g"ft. 41 `j ft. a in. (� SC ttqu p ven
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft- ft. e 11 �r 3 2 S d ` t, S
Monitoring ORecovery
Injection Well: �l
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licablc
-Aquifer Storage and Recovery ISalinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
(-Aquifer Test �IStormwater Drainage 4)ft. ,?ft. a V u r 1rGt vt
Experimental Technology IQ(Subsidence Control
bGeothermal(Closed Loop) ((Tracer .20.DRILLING LOG(attadvadditiunal sheets if necessar)'.
FROM TO DESCRIPTION(color,hardness,soillrock t e, rain size,etc.)
_ Geothermal(Heating/Cooling Return) . I Other(explain under#21 Remarks)
y r,10 0 ft. �l ft. .hJ S O 1
4.Date Well(s)Completed: �' l—�'`'L Well ID# ft. o�� ft. ` G
9 ft. ft. ` t.,°
Sa.Well Location: ` mix
��1 fA�, ��a 1��51�� �►s 2 ft. ft. GtL t'i[G+
Facility/Owner Name y 9 L Facility 1D#(if applicable)
le) ^�( �� ft, 63
2 ft. 41_rCA`
T�l I e r-A l-1 �� W !\ ]C�� o��l�IV t .�C`�'3� ft. 1Q J ft. .� ,�•- :-`,�
Physical Address,City,and Zip / ` ft. ft.
Jett b3/YoGTetolog- 21.REMARKS _
County (Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
6.Is(are)the well(s)�I"�.Permanent or (©(Temporary rgnature of itified Well C tractor Date .
TT , By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in formation at d explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remark 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-I 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: 63 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferew(example-3@200'jand�2@100� construction to the following:
10.Static water level below top of casing: I W (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: tY (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1A C V C1 TU V Y construction to the following:
(i.e.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
13a.Yield(gpm) Method of test: LAMP 1't\ 24c.For Water Supply&Injection Wells: In addition to sending the form to
VV the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1"f fi L+ Amount: I f- 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