GW1-2022-06793_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Lrfor tion:
1/ c - AJ
s 14:WATER ZONES
Well CcTara#Name FROM TO DESCRIPTION
bid ft.
l+6 L o A _ ft. ft.
V .
NC Well Contrac
tor Cettifi on Number , r 15.OUTER CASING for raniti-med~yells.OR LINER ri able.
FROM TO DIAMETETt TffiCKNFSS MATERIAL
Van vi 11 WWW ft. ft. . In. , 4 4 7 Z
Company Name �� . !►
C� 16.llVNER CA OR TUBING. eothermal closed-!
2.Well Construction Permit#: P,�rr_e� l FROM TO DTAMurn Tffiacros MATESUAL
List all applicable well construction permits(4e.V C,Couno,.State.Variance,eta) 11, ft. in,
3.Well Use(check well use): ft. ft. in,
Water Supply Well: I%SCREEN-
FROM TO I DIAMETER I SLOTSTZE I THICKNESS I MATERIAL
Agricultural unicipalt'Public it, ft. Ia.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. it is
htdustrial/Commercial DResidential Water Supply(shared) ig•G120UT
hri ation FROM, TO MATERIAL EMPLACEMENT METHOD II A1110UNT
Non-Water Supply Well: 0 ft. 20
Monitoring Recovery
Injection Well:
ft. it.
Illherinal
ifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK f a Ueabld
ifer Storage and Recovery Salinity Barrier FROM To MATERTAT. EMPLACEMENT MEHDOD
ifer Test fjStormwater Drainage ir. B•
eti-mental Technology ISubsidence Control ft. . ft.
thermal(Closed Loop). Tracer 20.DRILLING.LOG attactr additional sbeata ifGeo
ffeatinglConlin Return) 00ther(explain under#21 Remarks) FROM TO DESCMPMN color,hardoesy,BdUrock e. Inshz etc
0 ft. IL
4.Date Well(s)Completed:1 x �"�a Well ID# It 2 6• r q A rtg. G
5a.Well Location: R' R'
M u c k l�'t�S it. ft, g ��_p lr I
n �
Facility/Owner Name /� jj IfFacciilittyyWO(ifapplicable) it ft1 Se earl Prey ryc ,t ( I(t 5161110 J 7312, tt. ft. 2022
Phynsic)al Address,City,and Zip it. ft. cl J;-2
( hs�'� 21.REhiARIfS �dr ' i� -(tZ"'ITk', 1�1 1
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I
(ifwell field,one latAong is sufficient) 22.Certification:
N W 2
6.Is(are)the well(s)MrP ermauent or Temporary Signature of Cc c Well Contractor Date
By signing th form,I hereby certify that the wells)way(were)constructed In accordance
7.Is this a repair to an existing well: DYes or E4 with 15.4 NCAC 02C.0100 or MA NCAC 02C.0200 Well Constriction Standards and that a
it"is a repair,fill out known well construction information and explain the nature of the copy offloss record has been provided to the well owner.
repair under#21 remarks section or an the back of thisform. 23.Site diagram or additional well details:
&For GeoprobelDPT or Clese&Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constructifn,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: Z-V d (ft•) 24a.For All Wells: Submit this fortn within 30 days of completion of well
For mtdt(ple wells list all deptfu ifdiIfferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'."+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: (in.) 24b.k'Qr,Inleetton Wells: Ia addition to sending the form to the address in 24a
�. II above, also submit one copy of this form within 30 days of completion of well
1.c2.Well construction cable,
tloa method, a r r'oTc(tr Y construction to the following:
(ie.auger,rotary,cable,direcr push,etc,) ��
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �l 1636 Mail Service Center,Raleigh,NC 276994636
139.Yield(gpm) 8 Method of test- 24c.For Water Sminly&infection Wells. Ia 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:J1 �� 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