GW1-2022-06217_Well Construction - GW1_20220620

`Rent Form _,:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
01-11" •er t CGt.fG(J Q �/S t�/riY� 14.WATER ZONES
i �- FROM TO DESCRIPTION '
Well Contractor Name !-ft. ft.
�j ! J !7 ��
D 7 y ,4 ft. ft.
NC Well Contractor Certification Number n 15.OUTER CASING for multi-eased,wens)OR LINER if a licable
/ FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
�/ FROM TO DIAMETER ICKNESS MATERIAL TH
2.Well Construction Permit#: { �1 p�* 6L�Jr r 0�s�
ft. in.
List all applicable n•ell coaso-nction permits(i.e.U1C.County,State.Parlance,etc.)
ft.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: - ;Mti1i TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
IndustriaUCommercial Residential W�kT_[er Su ply(s�taJe�j fpUT
C, a „k-0--a �? FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri anon
Non-Water Supply Well: I I N � o 2 ft, ft.
Monitoring Recovery JUN ft. ft.
Injection V1'ell: P ^0�;`.-n tt.
Aquifer Recharge E3GroundwatellRMi6dlatleJ:,4, 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [DSaliniry Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. tL
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG attach additional"sheets if necessary)
FROM TO DES:RIPPTTION(ccolor,r,hardness,soil/rock type.grain size,etc.
Geothermal(Heating/Coolinng�Returrn) Other(explain under#21 Remarks) Q
4.Date Well(s)Completed. - 2 `-ZL Well ID/ '
ft. ft. r 0 r
5a.Well Location: / / a -r6`
Fd r fi e�- er GC�C�L ft. fL �O 6.r �% lNe,-tR r� ff J Ck
Facility ID#(ifa applicable) ft. ft.
Facility/Owner Name Y PP '
Physical Address,City,and Zip
JX� `. ,/Td N bl.REMARKS 1 (�
cot,n�✓ G( Parcel Identification No.(PIN) �+' `"SFr 6ve `� �'I'�0
rafter e�vt c e�s /�.�, ✓�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , 4-re M
(if well field,one]at/long is sufficient) 22.Certification-
3
S, 93L JoH N "SO- 213z-© �S� w
6.Is(are)the well(s) IPermanent or Temporary
Signature of Certified Well Contractor Date
Br signing thic.fornt.1 hereby c•ertiJi-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or [SNo with 15.4 NCAC 02C.oMo ar 15.4 NC,4C 02C.0100 Well Construction Standards and that a
If this is a repair,,ill out known well construction itybrmation and explain the nature o0he copy 4f 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-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: 6 D 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 ifdilferent(example-3@200•and 2 rc/001 construction to the following:
10.Static water level below top of casing: 22 S (ft.) Division of Water Resources,Information Processing Unit,
tfrvater level is aba✓e casing.use'•+„ 1617 Mail.Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�� C above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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&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: 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