GW1-2022-06220_Well Construction - GW1_20220620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
f11.,Well
lContractor Information:
W 1 ��1PN�(iVIlYlfJe� ��/ /nSCGGQC �ri 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3 G� / 6 A ft. S� r 0 ><�' S� fi`c i�( 44-
rt. rt.
NC Well Contractor Certification Number I5.OUTER CASING(for multi-cased wells)OR LINER if.a. linable
if a, `.C Ud e x�'//,A'` / FR0111 ft TO ft DIAMETER to THICKNESS MATERIAL
Company Name /N\ /'�V G_ J� 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 1 �L 5 P l �'t�1� Vat � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Hell construclion permits(i.e.UIC,CoungS State,Jar a •e,etc.)
fl ft. in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft, ft.
IndustriaUCommercial Residential Water Supply(shared) iS,GROUT
h'rl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ,ee�o;'ei n Cam' tt• ft
Injection Well:
Aquifer Recharge DGrou&e�Rq�tec @@ 2 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROat To MATERIAL EMPLACEMENT METHOD
e; t7 ,' ram.r, Un1.
Aquifer Test � tli] a /r
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock type.gnin size,etc.
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft / ft, i s?A
4.Date Well(s)Completedl�—2 Z Well ID# P / tt rA i5�i fJfL curs' S c v��
Sa.Well Location: s ft. ft. 6'o tN N S6
ft. ft. ;4// we,, Qeee r'o e P_
f outer- & flery lcck
ft.
Facility/Owner Name
' / f� Facility lD#(if applicable)
ft.
3 �U(iN9I O N A& ft.
Physical Address,City,and Zip
payn _ 21.REMARKSCounty
, vN Parcel identification No.(PIN).
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
�tCemer�t� r` S"�-►+� 1�w� j/',_ t•['/vf�'
(if well field,one lat11ong is sufficient) 22.Certification:
r
35-93) 933 N � 00o- W Z"� � CS=zz
6.Is(are)the well(s)oPermanent or NrTemporary
Signature of Certified Well Contractor ` Date
By signing this form,/herebr certffj-that the wells)was(were)constructed in accordance
7.is this a repair to an existing well: EDYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 lVell Cmtsn•uction Standards•and that a
//t r•.his is a repai fll out known well construction ilijorntation and explain the nature gfthe copy ofdtir record has been prorirled to the well on•net%
repair ander#21 remarks section or on the back g%this/brtn' 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 needed. 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 tnaltiple wells list all depths ifdijferent(e ample-3@200•and 2 cg100') construction to the following:
10.Static water level below top of casing: 2 5 (ft.) Division of Water Resources,Information Processing Unit,
!(water level is above casing.use••+(, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
S'o.�/ L 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& 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-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016