GW1-2022-06472_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Welt Contractor Information:
:�,�m, G �� KWATER?.ONE4
FROM TO DESCRIPTION
1Vcll Contractor Name
3 ' 1 70 ft• a�26 tL 1 uw
NC Well Contractor Cettificatum Number 13.CMMM (ibrnmid-ensed� OB LINER Qra e
� FROi! TO DIAM M THI MATis�tfAL ill —�S l he O ft. I•a ft. in. ID R 2 ' VC
Company Name
16.1NNER CASING OR TUBING(eothermal erased•
2.Well Construction Permit ff.a0 a a -O oo qZ FROM; 110 1 DIAn>t.M nncKNESS MATERIAL
Litt all applicable well consnction pem us(ix.U1C,Coalty,slate,Varlanw.etc.) Q R• $ ft' 16, et- m. 5 be ZI t" C-
3.Well Use(check well use): fL B'
Water Supply Well: 17.SCREEN
t�P y t)M! TO I DIAMBIER I st.OTSEM I THICItIVBSS I MATERIAL
Agricultural DMunicipaMblic R. R. Ian.
Geothermal(ieatinglCooling Supply) OR tlal Water Supply(Single)
IndustriWCommetcial C�tial Water Supply(shared) 16.GROUT
irrigation MOM TO MATERIAL, MPLACENIMTRIMOD& tOUN17
Non-Water Supply Well. O R• of l 1�hfaJort
Monitoring DRecovery . ft. CC
Injection Well: R. ft.
Aquifer Recharge E3Groundwater Remediation
.SAND/GRAVSL PACK Ikabie
Aquifer Storage and Recovery 13Salinity Barrier FROM: TO atATFtuAL EMPILACEMIUtT MermoD
Aquifer Test [jStormwater Drainage rt. IL
Experimental Technology [3Subsidencc Control ft• ft•
Geothermal(Closed Loop) DTraccr 20. LOG attach additianal siveti:if
Geothermal(Heating/Cooling Retum) E3Other lain under 621 Remarks) FROM To DnCRtPr10N talcs seuimac e. sbe.etel
D '� S( ft• al-
4.Date Well(s)Completed: I�l—a a well Il?0 flr. Vs-ft.
Sa.Well Location; ft. R•
yebOrmo LL ( . t
R. R. • Rs _
Facility/Owner Nam faeility IDS(if applicable) R' FL ?
U,r+;S C"Y k Ed Gznd?P2 i Xk Zf 11 et. a.
Physical Address,City,and Zip ft. ft.
!YZC'l�j
TOTU Q 2. tP 140
County Paul IdeatificatIon No.(PIN)
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suffidem) 22.Egon: d
W
6.1s(are)the welts) ermament or Temporary /SignaNre of Certified well Contractor Date
By signing this form,!hereby raiffy dwr the m-etl(s)uats(were)constructed in accordance
T.Is this a repair to an existing well: Dyes or 6No with 15ANCAC 02C.0100 or 15A NCAC 02C.02W Well Construction standards and that a
Ifthis is a repair,fill out knoun Hell construcdan itformutlon artd upf'a Cite nature of the copy of this record has been provided to the well*Hoer.
repafr under#21 remarks section or onthe back ofthisform. 23.Site diagram or additional well details:
B.Tor 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dri►lc d;
9.Total well depth below land surface: �r�� (ft.) 24a.For All Wells: Submit this,form within 30 days of completion of well
For multiple tells Ila all depths l/'dif jerent(example-3(200'and 2@1001 construction to the following:
10.Static water level below top of easing: (M) Division of Water Resources,Information Processing Unit,
If timer level is above casing,use"+ 1617 Mail Serviee;Center,Raleigh,NC 27699.1617
U.Borehole diameter. (o. Z,5 (in.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: R�.}a construction to the following:
(ix.anger,rotary.cable.direct push,etc.)
Division of WaiPr Resources,Umlergimund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 NO Service[eater,Raleigh,NC 276".16M
13a.Yield(gpm) —1/ Method of test: k \6't(1AV 24c.For Water Sara &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: C61 ar`np ` Amount: 3 4cL 6 completion of well consmictiom to the counl health department of the county
where constructed.