GW1-2022-06677_Well Construction - GW1_20220708

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WELL CONSTRUCTION RECORD (GW-1) For Iltternal Use Only:
1.Well Contractor Information:
14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3 8�' TZ A ft. rt.
NC Well Contractor Ccrtification'Number 15.OUTER CASING for multi cased)yells OR LINER if a Hcable)
�f \ FROM TO DIAM EF.R THICKNESS MATERIAI.
� (`'�,�s U�f.( C� l-J r�//� •'i:G7 i � T
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable cell construction permits(i.e. UIC.('oun(r,State. 1'a iance.etc.)
ft. ft. 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) oResidential Water Supply(single) ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl atlon FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. R.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAI. F.MPLACF.MF.NT ht F.THOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock e,grain size etc.
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks)
• �/4.Date Well(s)Completed: c� 2 Well ID# G I 10,""
ft. ft.
5a.Well Location:
f / 0. h_ /.,�'J L_L C
L nl et. rt.
Facility/Owner Name Facility ID#(it applicable)
/��///�� A"' ft. ft. •. .l.:.•,. 1nr:+A
I,.
ft. �ud et�.ci`Lht�7
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
,/� .-3�� ei":r l l t e'.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
Signature ol'Cenified Well Contras Date
6.Is(are)the well(s)oPermanent or OTemporary
Br signing This firm.l hereby certiJi,that the u•rllLs)ivus(acre)cnnsnurred in ace•urdunce
7.Is this a repair to an existing well: nYes or R)No ii-ah 15.4 NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Smnrlards and that a
/(this is a repair,ill out known well construction information and explain the nature of the copy of this record has been provider/tn.the well owner.
repair under#21 remarks section or on the back of this(orm. 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: I L9 (ft-) 24a. For All Wells: Submit this font within 30 days of completion of well
For multiple wells list it//depths it di[frretl(example-3@il.200''and 2(ct l00') construction to the following:
10.Static water level below top of casing: ' 7 (ft.) Division of Water Resources,Information Processing Unit,
lfivaierlevel 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 font to the address in 24a
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 C I enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of'test: 24c.For Water Suimly& 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.
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Form GW-I North Carolina Department of Fnvironmental Quality-DiN ision of Water Resources Revised 2-22-2016
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