GW1-2022-06215_Well Construction - GW1_20220620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: J)
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
.1 s ft. S.O ft. 54 CD )' e --SLr � A,,?.,Ter
ft.
NC Well Contractor Certification Number 15.OUTER CASING forlti-eased.weBs OR LINER if ap ticable
mu
t FROM TO DIAMETER THICKNESS M1IATERIAI.
C�scc,&e l�r;J/%tip G°
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / L�r • ) �'• L'� / B vG- FROM TO DIAMETER F.TER THICKNESS PIATERIAI.
List all applicable irell consintetion permits(i.e.UIC.Cotuuv,Stare, ariance,etc.) ft, ft. in.
in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Sypp ti, llef ft, ft. in.
Industrial/CommercialResidentiVfat $%ippl .(spar@il) jgGROUT
IIII stria r FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 13 Recovery T , 11n;ti R, ft.
Injection Well: "1 t (_�
J }C�C,F;�ivs�tlr• ,C,L1�l:i ft. ft.
Aquifer Recharge E3Groundwater Remeti6n 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. F.M PLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. To
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if nece'ssar
FROM TO DESCRIPTION(color,hardness,soiUrnck type, rain sac,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) © ft.
f 13 ft. ed iA rb cwr✓ +-a Irk-
4.Date Well(s)Completed: ~• . ZZ Well ID# S�LJ m / 1 3 ft' D et'
5a.Well Location: I eft. ft. ��bd� 6✓ o//
✓-b iw 01 e f' AaA e r-y l f+'(:i'i ft. ft. tr-�:♦�/s
Facility/Owner Name LiI Facility ID#(ifappflicable) (� ft. 'D ft. �� rlk, e,1 .Ct< $
Physical Address,City.and Zip
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) G C� Wigg*naturc
tifi atioh: r
6.is(are)the well(s)oPermanent or �If Temporary
of Certified Well Contractor Date
By signing this f n-nr,/herebr certify then the wel/(s)eras(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or Wo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair•fll out known well construction it fornnation and esplain the nature gJ'dte copy of this•record has been provided to the well owner.
repair under#21 remarks section or on the back of lnis.fornt. 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 I GW-I is deeded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3@200'and 2 6:100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
fwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (V (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.0 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 Fi,-'UJ 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method 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: Amount: 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