GW1-2022-06800_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD (GW D For Internal Use Only:
1:Well Coidractor Information:
i
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ae1 ft. /to ft. 1 ; Yh
NC Well Contractor Certification Number it. t�p ft.
15.OUTER CASING(for"vrulti-eased we R LINER if licable
ra Nit well i
fvw
FROM TO DIAMETER THICKNESS MATERIAL
C � It.
ft. In,
Company Nome I l V 16.INNER CASING OR TUBING: eothermal closed400
I
2.Well Construction Permit&L e � q FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Coumv,State,Variance•etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft• ft. 16'
Geothermal(Reating(Cooling Supply) BlIcsidential Water Supply(single) 1
ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
1rri at on FROM TO MATERIAL EMPLACEtIEW METHOD&AMOUNT
Non-Water Supply Well: V it. 2 p it. G „
Monitoring Recovery ft. it
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVELPACK 'a cable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL. EMPLACEMF.NTMETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothemlal(Closed Loop) E3Tm= 20.DRILLING LOG attachadditional§heets tfnecessary)
Geothermal eatin Coolie Return) Other(explain under#21 Remarks FROM TO DESCRIPTION rnlor hardness sa8lrock a In size.etc.
/ ft. 50 ft yk
4.Date Weil(s)Completed: �1. ? Well ID# Q ft. s
Sa.Well Location: / ft• 0 0 ft• i!a h G
-
FacilitylOwner Name Facili IM(ifapplicablc) ft. It.
_� A�/V►�l►�uY' 1 2 l:I C4 h t e V�r�7yS ft. ft. ; �'l A t• 'a r p i''�c
Physical Address,City,and Zip --r-t ft ft•
701 I l - S I Jq 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: „
(ifwell field,one Wtong is sufficient) 22.Certifl d
6.Is(are)the wells); Permanent or Temporary Signature of crtitied Well Contractor] Date
By signing this form,I hereby certify that the wrl1(s)was(xwre)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this 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 under 021 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
constructi ,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z4a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3Qa 200'and 2 @100) construction to the following:
10.Static water level below top of casing: o (ft) Division of Water Resources,Information Processing Unit,
Ifwater level 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 form to the address in 24a
12.Well construction method: Me- above, also submit one copy of this form within 30 days of completion of well
/,/�7i ✓ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) T
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
G I
13s.Yield(gpm) -1 Method of test: ��`J 24c.For Water Sunuly&Ini I Hon 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: '1 Amount: Z 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