GW1-2022-06463_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
i
1.Well Contractor Information: f
14 WATERZONFs
Well Contractor Name FROM TO DFSCRPTION
NC Well Contractor Certification Number ^P p t � 2�'t'Z -IEOU1ER"G tSIlVC=([o%m" li tl cats t:i-4ns"DIULIIVFR�(it;a`ntalileanow
S I n C (1 R 1 FROM TO DUME7ER TMCRNFSS MATERIAL
ft. ft. in.
Company Name It�Ot7D OOG 16'INNER.CASINGOlt TUBING eathermai'closW466 ) '_ z "
2.Well Construction Permit#: DWW FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(Le.UIC.County.State.Variance.etc.) ft. ft• Irt• a '
3.Well Use(check well use): ft. ft. in.
-M,SCREEN,f.,,
.. ,
Water Supply Well: FROM TO DU+MEIER I SLOTSIZE THICKNESS I MATERIAL
Agricultural M ipal/Public ft, ft, in..13
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• ft.
Industrial/Commercial [31tesidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (2 ft C) ft• (-a h t PO 1 k 12
Monitoring Recovery ft. ft. Olt
[Experimental
tion Well:
uifer Recharge Groundwater RemediationuiferStora and Recov Salini Barrier 'SAND/GRAVEIlPAG&ifa liabl ge ray ty OM To MATERIAL EMPLACI9NEPrr METHOD
uifer Test ®IStormwater Drainage Technology Subsidence Controlothermal(Closed Loop) 13Tracer20 DRIILING`LOG:Sttach additib"I t`h"ifFROM TO DESCRIPTION color bardne soillrock nsia etc.othermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 r 3
4.Date Well(s)Completed: 3-a a��2 Well ID# ft• I�G 6�
Sa.Well Location: ft• ft'
Facility/Owner Name Facility IDS(if applicable) ft. ft.
11 ft. ft.
10� Lioo ICI ��� TYQ, ��T tY
Physical Address,City,and Zip
21 REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one lat/long is sufficient) 22.Certification:
3.5` A ' ,?1- 0ggz3'N i�
3),1� s1 t l W
6.Is(are)the wells) ermanent or ['Temporary ,,; nature of Ce ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ythis 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 tinder#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
9.For GeoprobetDPT 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-1 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: D CZ� (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhip/e wells list all depths if d)i ferent(example-3Q200'and 1Q100) construction to the following:
I
10.Static water level below top of dosing: Lo d (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use^+' 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter•. (,, 2 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/JY� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (L 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) oQ, Method of test: ,rAQ 24c.For Water Supply&Injection Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:,CL I Dr,0,4 _ Amount:�n t�f s I,S 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