GW1-2022-05910_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatiion,:/
CX7 S O4 el G,CA/ , 14.WATER ZONES
Well Contractorf4ame FROM TO ,tD�ESCRIPPGT'ION
%ft. ft. 2A
NC Well Contractor Certification Number / 15.OUTER CASING(for multi-cased wells)VOR LINER it a livable
47 1fi t/per ` FROM TO DIAMETER THICKNESS MATERIAL
V v rp ? ft. ft.
Company Name {O
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) +f:
ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nM icipal/Public ft. ft.. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
1ni ation FROM TO M TERIAL EMPLACEMENT IETHOD&AMOUNT
Non-Water Supply Well: O tt. 040
Monitoring ORecovery ft. tt.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
`19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. u.
Geothermal(Closed Loop) Tr'aeer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
Geothennal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: S� a�i Well ID# ft. Soft.
5a.Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. '° "` .. z
9Y5© //,,/ X7 tt• JUN 2912072
Physical Address,City,a d Zip ft. ft.
21.REMARKS - ': ., n r.. __� •.,.:;� nil,r a tn'r'ti
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,Boyne lat/long is sufficient) 22.CertificatiAtOSU N / I S( ' 12 W6.Is(are)the well(s) Permanent or Temporary Si tare of Ceni Date oS
By signi ris form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No 3A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature o copy of this record has been provided to the well owner.
repair under#21 remarks 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 5y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'aid 2@100') construction to the following:
10.Static water level below top of casing: / 9 (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: (l/ (in.) 24b.For Iniection 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: G kv 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: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Ole, 24c.For Water Supply&Iniection 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: Amount: b*MUz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016