GW1-2022-06799_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
6Q Le, S 14.-WATER ZONES
Well Contractor-Axame FROM TO I DESCRIPTION
ft. Oft
ft. ft.
NC Well Contractor Certification Number
is,OUTER CASING ifor multi-casedweUB OR LINER if: livable
FROM I TO I DIAMETER TMCKNESS MATERIAL
W D it. ft. in. '/G
Company Name J� tt 16.UMRCASINGURTURING..(!eothwmsiclosed400
2.Well Construction Permit#: G P♦, @ J �3 ' FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable•tvell construction permits(l.e.UIC,Count).State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. tt,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)Kln
ft. $dustrial/Commorcial Residential Water Supply(shared)
18.GROi1'r
rri tion FROM TO MATERIAL EMPLACEPr METHOD&�AXIOUNT
Non-Water Supply Well: ft. 0 ft. h
Monitoring Recovery ft. n.
Injection Well:
ft. ft.
Aquifer Recharge [DGrroundwater Remediation 19.5ANO/G12AYEL.PACi{(if a livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL. V EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage % fL
Experimental Technology OSubsidence Control ft. ft. i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additions!sbeets if neeessa
Geothermal(Heating/Caolin Return) Other explain under#2I Remarks} FROM TO DESCRIMrON color.hardn I/roek e, insiz etc.)
ft. to ft. �Q
4.Date Well(s)Completed: 'Z2 Well ID# 10 ft. ft r-4
Sa.We I Location: ft. ft.P2 Cf A ka
Facility/Owner Name Facility ID#(if applicable) ft rL
$33� Wa(cc �wY . Rot I-c la k 7613 f' ft.
�q
Physical Address,City,and Zip ft. ft,
_pf,A any 2L RE5L4RXS
County Parcel Identification No.(PIN)
`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: i"tli{,i'Yivili�i('!pff L/j �)�UK1f
6.Is(are)the well(s) Permanent or Temporary Signature of C
ced well Contractor DateBysigning tlm,I herebp vertu that the wiell(s)was(were).constructed in accordance
7.Is this a repair to an existing well: E]Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cmnstniction Standards and that a
If this is a repair,f ll out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 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 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q 0 0 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'aud..�}a/005 construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Resources,InformatlonProcessing Unit,
If pater level is above casing,use"+"r 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: W (iu.) 24b.For Infection`'yells: in addition to sending the form to the address in 24a
12.Well construction method: Q r6��P y above,also submit one copy of this form within 30 days of completion of well
(La.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: ''I 1636 Mail Service Center,Raleigh,NC 27699-1636
V"
13a.Yield(gpm) J Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
1 the address(es)'above, also submit one copy of this form within 30 days of
13b.Disinfection type: N Amount: completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina DenartmentnfF..nvirnnmontalrl. 146, .Pklr,.aD- -