GW1-2022-06888_Well Construction - GW1_20220718

Print Form.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: it
1.Well Contractor Information: i l
A
6-M 6/0I /Y)IJ(�t �• 14.NVATER ZONES l I
FRONI TO DESCRIPTION
Well Contractor Name / ft. ft.
3 7� A ft. l ;
NC Well Contractor Certification Number (� 15.OUTER CASING for multi-cased wells OR LINER(if a livable)
FROM TO of A..,,
ISR TIIICKNICSS 11ATERIAI.
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit 4: FROM 'ro oL 1u`TFu THICKNESS 11.vr1:R1,u.
Lieu all applicable nrll emcrn'aeliuu prratNs li.c•.CtIC.Caunn•.Stnlr, I$rriancr,cvc.)
ft. ft. in.
3.Well Use(check well use): ft. ft. itt•
Water Supply Well:
17.SCREEN
pp F•RO'M TO DIAIIFTER SLOTSI7.E THICKNESS MATERIAL
AgriculLLIMI Municipal/Public ft. ft. in.
Geothermal(Ideating%Cooling Supply) DIResidervial Water Supply(single) ft.
Industrial/Commercial DResidentiat Water Supply(shared) Is.GROUT
Irri anon FRolt TO MATERIAL E11rl.:�cF:uENT 1IE'ruoD c AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring �Rccoveq• ft. ft.
Injection Well: R ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a ilicable)
Aquifer Storage and Recovery Salinity Barrier FR011 TO M,%TERIAL F:1IPLACEIIF.NT\METHOD
Aquifer Test DStonmvaterDriinage ft. ft.
Experimental Technology DStibsidence Control ft. ft. I`
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM to DESCRIPTION(cnlor.hardness.snillrock tv e,Brain size,etc.)
Geothermal(I'leating/Coolin_Return) Olhcr(explain under t{21 Remarks) R. ft. ',r ,V u
4.Date Well(s)Completed: _2-0_Z Well ID# r fi. ft.
ft. ft.
5a.Well Location:
c ,
Facility/Owner Name Facility IDB(tt'applicable) ft. ft. I I j( 2027
7 9 7 Od P a 1 t 1 R ft. ft. J v
•� L3�='w�""ITS
Physical Address.City.and Zip ft. ft. �� s.-
, 'I('�h /c?ryz�i l" 21.REM ARKS I rrVr M CEM I
County Parcel Identification No.(PIN) / ��P
SO �U rYC y(�/C_d r.
5b.Latitude and longitude in degreeshninules/seconds or decimal degrees:
��M /."�v- W i}h h IPraf�r���. GP,.�r.V,• i`E' :.ells
(if well field,one latilon,is Suflictcnt) 22.Cerliticalion: II
s.� ass �- �� 71L 2�) W �� /
6.Is(are)the w•ell(s)OPerm:ment or Temporary Signature otTertified Well C•ontrauo; Date
By signing this firm./herehr vertilij that the url/lsl was rneret cansimoctl in accordance
7.Is this a repair to an existing well: Yes or [ONo widt I5A.\'C.AC u1C.0M')or I5A NCtC 02C.0200 Irgl C'unsuvrtion Slundards and that a
if Ihi.r i.v a repair.fill nw knomt well rnnsu'urtu+n inlin•ntatiun and erplain the nanar al the copy ul-this record has been provided to,the well ot,ncr.
repair wuler;;2l remark c xenon or on the hack o/'lhts.torm
23.Site diagram or additional well details:
8.For Geoprobe/DIIT,or'Closed-Loop Geothermal Wells having the same You may use the back of this p;igc to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL.NLJM13ldZ ol•wclls construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INS'I RUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit ihis form within 30 days of completion of well
For nadliple wells hem all depths i(difje•renr(rxwuplr-3(;t2r70'dad'l is ItJl.1•)
construction to the litllowing:
10.Static water level below top o[casing:�r (ft.) Division of Water Resources.Information Processing Unit.
water leer/a above ru.,ing.u.,'r")" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241).For Injection Wells: In addition to sending the font to the address in 24a
So Al/'� above. also submit one copy o�this Iiinn within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger•rotary,cable•direct push.etc.).
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WILLS ONLY: 1636 Mail Service Tenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunniv tC Iniiciion Wells: In addition to sending the fomt to
the address(es) above. also sdbtitii one copy of this forni within 30 days of
13b.Disinfection type: Amount: completion or well construction �o the county health department of the county
where constructed.
Form GW-I North Carolina Depanntnn ofl:mironmrntal Quality-lhs iston of\eater Re.oiaccs Revised 2-22-2016
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