GW1-2022-06036_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD(GW=11 For Internal Use Only:
1.Well Contractor Info n:
FROM DUCRIPrION
Well Contractor Name
O C1 S ft. fL
W .
Well Contractor cation Number
FBA ft TO O tt• D min. �(�1 ��C
Company Name .
2.Well Construction Permit#• L-)A'O PROM TO DUMETM
TMCKNFSS MA
List all applicable well conshvetionpaWts(i.e.U1C.County,Srate Variance,dr-) 8 fL b fL - -4 Lej 4-a
3.Well Use(cheekwell nee):
Water Supply Well: FROM TO DL k SLOT SUZ THIC�S MATERIAL
Agricultural [3MunicipaUPublic & & 1a
Geothermal(Heating(Cooling Supply) DResidrotml.Water Supply(single) g. g, to.
IndustriaUCommercial Residential Water Supply(shared)
Iiil �On
FROM TO MATI BiAL ENMIA METHOD&AMO
xea-Water Supply Wall: 0 � 5 & a
Monitoring Recovery & ft.
Injection well: ft. &
Aquifer Recharge C)Cuotmdwatea Remediation
Aquifer Storage and Recovery- DSalinity Barrier FROM TOZMA:TERUL EMPLACEMENT M9MOD
Aquifer Test 13Stomiwater Drainage &
Dgicrimeetal Technology 13Subsidence Control �•
Geothermal(Closed Loop) Tracer
Geothermal eaton Coolin Return Other lainunder#21 Remarks FROM TO DFS ON eotor hardn soW etc
m �5. �'
4.Date Well(s)Completed: Well ID# +(
Sa.Well Location: `L 5 D' R' C,Cc t c t✓ ,r+-1
O ft. p
iL
Facility/Owner Name Facility ID#(if applicable) &
ft tb
1` 1 Address,City,and Zip
sty Parcel Identification No.M _ �l E-5
ifcl':i:'Infi� ^ =''i�(l�..l;:)�;y;'.i7JI'I
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) -1/ 22.Certification: n
N 1 0j �� w " Jh a�w` a
nA
6.Is(are)the well(a)OPermanent or Temporary Signature of Certified Well Contractor - D
By signing this form,I hereby certify that the wea(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeU Construction Standards and that a
If this is a repair,fill out known well canssduction information and erpiain the native of the copy of this rewrd has been provided to the well owner.
repair under#21 remarks section or on the.back of thisform.
23.Site diagram or additional well details:
8.For GeoprobelDPT or Close&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 we construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aU depths ifdMerent(example-3@200'and 2@1001 won to the following.
10.Static water level below bop of acing: a\�. O (fL) Divhdon of water Resources,Information Processing Unit,
If water level is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v (in.) 24b.For election WeHe. In addition to sending the form to the address in 24a
�p opt above,also submit one copy of this form within 30 days of completion of well
1L Well contraction method: — I construction to the following-
(Le.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) —t Mefhod of test: 24c.For Water Supply&Injection 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: A`rA Amount: e'er - completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016