GW1-2022-06832_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD(GW 11 For Intemal Use Only:
1.Wen Contractor Information:
yt�1 a t�i VATER ZONES 6
c 0 1 Q�L FROM TO DESCRIPTION
Well Contractor Name %
NC Well Contractor Certification Number 15s.OUTER CASING er nmlil-cned wdh fNl liiMR- Ilenble
FRObt TO DIAMETER THICKNESS MATERIAL
r 4 Palo w W+ D, ft. 3 ft. In. vCJ
Company Name '16.DMRCASINGORLUBING owmd'rlaudd
2.Well Construction Permit#: — b ;�02�, FROM To aunteFEs TsfcxNEss MATT RtAL
List all appRoable•well construction uls(1.e.U1C,County:State,V-Imce,etc.) R• R' lm
�
3.Well Use(check well use):
Water Supply Wen.. 1moM 1. TO DIAMETER BLOT SIZt3 THICKNESS MATERUL
Agricultural Municipalfthlic ft. it, In.
Geothermal(Heating(Cooling Supply) BRoddeatial Water Supply(single) ft. ft lta
ludustrriai/Cotnmcrcial Residential Water Supply(shared) 18.GROIUT
Irrigation NSAN'DIC
TO MA EWLA METHOD&AMOUNT
Non-Water Supply Well: R' VMonitoring Recovery 9.
ejection JAquifix
quiferRecbarge �GroundwaterRemediationRAVEL:PACK i ticable
quifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL MPLACEMENT METHOr)
Test [)StormwaterDm1nage ft. ft.
xperimeatal Technology Subsidence Control ft.
!
eothermal(Closed Loop) EITtacer 20.ARn1J[VGLOG' addido"vstieeaffnecea
eothetmal eatin Coolie Return Other lainunder#21 Remarks) OFROM TO nascRrnrtox cokr Horan `ioSUrocit
Idy
_-'��.4 Dtitewen(s)Completed: ^2 17, Well ID# b IL a0 w qt fi roc k
- ft
Sa:Well Lee ti : ^'
Cart Gh n n. B G r.-�..
Facility( Name Facmity lDtl(if applicabic) R' R' r`
ft.
UL
P61cal Address,City,and Zip; T �_— ft. ft.
at
Cow* Parcel identification No.(PIN)
i
5b.Latitude and longitude in degrees/mlrmteslseconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification: I,
I'
N W
6.h(pre)the wells) 'r Permanent or TemporarWNo
Signature of 'fled Well Contractor t i Date
By signing this form,I hereby certify that the well(s)was(were)comwucted in accordance
7.Is this a repair to an existing well: NrYes or ulth 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Smndardt and drat a
If dug is a repair,/lil out knmvn well construction h formatlon and explain the nature of the copy of Als 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.
&For GeoprebelDPT 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.
drilled: ! SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 Z 0 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lisl all depdn 1f dderent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: t7 (ft) Division of Water Resou roes,Information Processing Unit,
trwaxer level is above casing,tide"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
C '
11.Borehole diameter: (tn.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: trb k✓Y above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �, 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of. Dui 24c.For Water Sumly&Iniee`on Wells: Tn 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.
IR—t:ou.t North Carolina DeMiroent of Euviro=-tal Quelky-Division of Water Resources; Revised 2.22-2016