GW1-2022-05678_Well Construction - GW1_20220616

WELL CONSTRUCTION RECORD(GW-1) Fo nternal Use Only:
1.Well Contractor Information:
14. TER ZONES
�- FRO TO DESCRIPTION
Well Contractor Name ft. ft.
�I
`V4VWG ago
NC Well Contractor Certification Number 15. TER CASING for multi-cased wells)OR LINER(if a licable)
tA)c p� �y a FRO TO DIAMETER THICKNESS MAT�ErRiAL
Z%q1.6 lt` ft.
Company Name 16.I NER CASING OR TUBIN thermal closed-loop)
2.Well Construction Permit#' FRO TO DIAMETER THICKNESS MATERIAL
in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft.
nt
3.Well Use(check well use): it. ft. I in.
Water Supply Well: 17.S BEEN
Ap Y FRO t I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural Municipal/Public ft. I ft. I in,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. I ft.
Industrial/Commercial Residential Water Supply(shared) 1S. OUT
Ini ation FRO TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O, ft. ft. Q
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Remediation 19.S ND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier —MR-0-P TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.D 1ILLING LOG(attach additional sheets if necessary)
TO DESCRIPTION(color,ha dress,soiUrock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. �A ft. emm
4.Date Well(s)Completed: l9_13_,Q Well iD# ft. ft. T.,c
ft. ft.
5a.Well Locat,
0_ �7r�
FRO l ' ft. ft.
t Facility/Owner Name Facility iD#(if applicable)
ft. ft.
Physical Address,City,and Zip
MMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.C rtification:
N W I l0_ 11J`02
igt re of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary
• By si ing this fornn, i hereby certi%y that the well(s)was(were)constructecl in accordance
7.Is this a repair to an existing well: []Yes or,& with 1 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!/'this is a repair,fill out known well construction iujormation n explain the nature o/'due copy , this record has been provider!to the well owner.
repair under#21 remarks section or on the back of this form. 23.Sii e diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You r iay use the back of this page to provide additional well site details or well
construction,only t GW-1 is needed. Indicate TOTAL NUMBER of wells
const ction details. You may also attach additional pages if necessary.
drilled: ( SUB ITTAL INSTRUCTIONS
�f
9.Total well depth below land surface: f ac c (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'di(1erent(example-3@200'and 2@I00') const ction to the following:
10.Static water level below top of casing: "C�J (ft.) Division of Water Resources,Information Processing Unit,
11'water level is above casing,use'• " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For In•ection Wells: In addition to sending the form to the address in 24a
c abovel also submit one copy of this form within 30 days of completion of well
12.Well construction method: I Cz r U 12e const action to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Di ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t'
13a.Yield(gpm) lb Method of test: l _ 24c. or Water Su I & In•ection Wells: In addition to sending the form to
r p the dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Y'CL►L V l Amount �® com 1 tion of well construction to the county health department of the county
where,constructed.
n—kad 2-22-2016