GW1-2022-05679_Well Construction - GW1_20220616

WELL CONSTRUCTION RECORD(GW-1) F r Internal Use Only:
1.Well Contractor information:
`` I Inn 14. ATER ZONES
Well Contractor Name FR TO DESCRIPTION
�1.�1V 1, a" y " �- ft. ft.
NC Well Contractor Certification Number
< 15. UTER CASING for multi-cased wells OR LINER(if a a!le
o di
I i FR TO DIAMETER THICKNESS MAT�EpRiAL
v'3ft. t ft. 25 in. spr � V L_
Company Name ® Y
16. INNER CASING OR TUBING(geothermal closed-too )
2.Well Construction Permit#: FR TO DIAMETER THICKNESS MATER►AI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17. REEN
FR TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 19. ROUT
Irrigation FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. , It.
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19. ND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FRo TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.11 RILLING LOG(attach additional sheets if necessary)
Iii Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRo TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
�s ft. aft.
4.Date Well(s)Completed: Well ID# ft• ft• c
5a.Well Location:
FAA ft. ft.
"11(� t�Y1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
.4-Ll!1a Z56FZn1 1 �_ S 1� on ��e
Physical Address.City.and Zip ft. ft.
D&.on 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W d
�A-A(1
6.is(are)the well(s)�I)<'ermanent or Temporary tANCAC
ed Well Contractor Date
��VV te,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or o 2C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is arepair,fill out known well construction inforuallon an explain Hue nature ofthe has been provided to the well owner.
repair under#21 remarks section or on the back of this firm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You I hay 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 constr iction details. You may also attach additional pages if necessary.
drilled: R SUBMITTAL INSTRUCTIONS
�P��
9.Total well depth below land surface: PAX, (ft.) 24a. or All Wells: Submit this font within 30 days of completion of well
For nnilliple wells list all depths i/'di#ereiit(example-3@ 200'and 2 rb100') construction to the following:
10.Static water level below to of casing: t
p g: (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: LQ (in.) 24b..Well construction method:JiL Il or In•ection Wells: In addition to sending the form to the address in 24a
,6 �, l?a Pry abov also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) constction to the following:
Di fision 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: 24c. r Water Supply& in•ection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount:__ comp tion of well construction to the county health department of the county
when constructed.