GW1-2022-05913_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-.
CJJ4"S1� 14.HATER ZONES
Well Contractor Name FROM TO DESCRIPTION
y •��,p ft. ft. G� s�
'a 4�
Kell Contractor Certification N mbcr "- 15.OUTER CASING(for multi-eased wells)OR LINER if a licable)
r FROM TO DIAMETER THICKNESS MATERIAL
�. ft.'1!24 ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. J.t in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
1rri ation FROM TO k4ATER14L EMPLACE ENT METHOD&AMOUNT
Non-Water Supply Well: D tt. tt.
Monitoring Recovery
Injection Well:
_ ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilfrock e,grain sim,etc.)
Geothermal(Heating/Cooling Return) Other(explain tinder#21 Remarks) ® ft. ft. U
Q
4.Date Well(s)Completed:U ��Zell ID# ft. ft.
VY
5a.Well Location.
Facility/Owner Name Facility ID#(if applicable) ft. ft. `' v br 1
9q G(o*Ni d15 � � Pei ka), ft. JUN 29 7 2022
Physical Address,City,ant Zip ft. ft.
��SV`eC11.1' �Z� ®� 21.RENIARKS ri..,xs.^;:'.,. 0ni:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is s}ifficient)3 �} ( 22.Cc • atio Z?, N ° Z9.3� W '004
6.Is(are)the well(s) Permanent or 13Temporary Signature o ed ell Contractor Date
gning this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2i remarks section or on the back ofthis fain. 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: Jr A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z`A"' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 rei 200'mud 2Q100) construction to the following:
10.Static water level below top of casing: 17 (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: (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: construction to the following:
i._
(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) S Method of test: sf 24c.For Water Supply&Iniection Wells: hi addition to sending the form to
Z& the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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