GW1-2022-06825_Well Construction - GW1_20220715

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VL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i.Weli Con ctor information:
14.WATER.ZONES
Well ContrarctorrN FROM TO DESCRIPTION /y.
tr
t N o ft. T� R' 5� rn
--r ft. R.
NC Well Contractor Ce ' on Number 15;0UTEIR CASING for multi-cased wells OR•LINE&if i Ueable
L-1fa4 o6f't FROM TO DIJAMUER T11I0KNESs MATERIAL
% ft. i; in. V Q V
Company Name
g� K INNE1t CA9 G-OR TI18IN eothei+tiat closed-iuo
2.Well Construction Permit#: ti'11 4x) FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r)e.UIC,County;State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 173CREEN -
FROM I TO DIAMETER I SLnnmr fTTiiCKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EgResidential.Water Supply(single)
ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) i8 GROTTY
Irrigation FROM TO MATERIAL FAMAGEMENT A OD&AMOUNT
Non-Water Supply Well: O II, o ft.
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation R• ft.
kAquifer Storage and Recovery �gg,5ahini. Barrier 1�'SAS/GRAM PACK ifs-applicable)
B..l ty FROM TO MATERIAL. EMPLALE11iENTDLErIIOD
ifer Test [3Stormwater Drainage
ntal Technology Subsidence Control ft. ft.thermal(Closed Loop) Tracer 20.DRILLINFx LOG ttach additional sheets tfthermal(Heatin Conlin Retum) Other(explain under 421 Remarks) FROM TO DESCRIPTION eclor,Bards soiVrack rain eta)
fY. 0 ft. k
4.Date Wells)Completed: Well ID# 90' 3 30 it.
5a.Well Location: R• ft II
Facility/owner. ame R. ft. -
Facility D#(ifapplicablc)
0 1 ��l;G��� & ls.�-a ft. ft, a -
J
Physical Agddddress, yy ,and Zip ft. ft. �
21.REMARKS „r UNI-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field,one lat/long is sufficient) 22.Certlt➢cation:
N W �
6.Is(are)the wells)fdPermanent or Temporary Signature of C ified Weil Contractor Date
By stgning this form,1 hereby cerli�that the uell(s)was hvere)constructed in accordance
7.Is this a repair to an existing well: ElYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fug out known well construction information and explain the nature of the copy ofthis record hits 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
constructio ,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages,if necessary.
mod: — — SUBMITTAL INSTRUCTIONS I,
9.Totai well depth below land surface: -
i
For multiple wells list all (R') con For All Wells: Submit this form within 30 days of completion of well
p depths ifdt•fjerent(example-3'(a)200'and 1Qa l00'j construction to the following:
10.Static water level below top of casing: (�0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+f" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _I13 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: cur n 4r l above,also submit one copy of this fort within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta) construction to the following:
FOR WATER SUPP X WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 276994636
13s.Yield(gpm) Method of test: 24c.For Water Sumly&Infection Wells: In addition to sending the form to
AAle address(es) above, also submit]one copy of this:form within 30 days of
13b.Disinfection type: Amount: Q. completion of well construction to the county health department of the county
where constructed. ;
Form aw-I North Carolina Department of Enviromnental Quality-Division omiterResotuces 1 I Revised 2-22-2016