GW1-2022-07139_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
tif�ri'tI J
l`'/` Jam- 44.,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Za 2i4-4
NC Well Contractor Certification n um
a .15:'OUTER CASING'Por meld=cased wells OR LINER'(if:e llea6le '
�A ( c I _ , J mac' FROM TO DIAMETER THICKNESS MATERIAL'
r�� (/� ft. " Li�ft. in. (-2 C
Company Name
'�I6IlYNER CASING_ORTUBING'C eothermal•closed+loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft• '�
17 SCREEN_;.;.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in..
Geothermal(Heating/Cooling Supply) i esidential Water Supply(single) ft. ft. in•
Industrial/Commercial OResidential Water Supply(shared) I GROUT. .
_: hTi atlon FROM TO MATERIAL EMPLACEMENTMErHOD&AMOUNT
Non-Water Supply Well: ft. 22- ft 3 tt 1 tit G
Monitoring i- Recovery % ft. i A
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
-19.SANDIGRAVEL PACK(lfa`licable).. ::
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 2O.DRILLING;LOG attach additional sheets if n
lGeothermal
eating/Cooling Return) _ Other(explain under#21 Remarks) FROM ft. ft.TO DESCRIPTION(rotor,hardness,soNruek size,ete.)
� 2
4.Date Well(s)Completed.. 7-�—O'ZLWell ID# �S N3 ft Z ft'
5a.W91 Location:
ft. ft.
Facility/Owner Name Facility IDIi(if applicable) ft, ft.
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutedseconds or decimal degrees:
SOG
(ifwell field,one lat/jong is sufficient) 22.CerhficatiCsio �
6.Is(are)the wells ermanent or Te o of Certified Well Con c Date
() mp racy
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an Blasting well: 13 ,
Yes or P4 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out latown 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 farm.
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.:-
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S 00 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: ,
10.Static water level below top of casing: Z� (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l/l o" construction to the following:
(i.e.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test.. °3/C�,t\ 17,6c.For Water Supply&IniectioD 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: Amount: b(.w_ s completion of well construction to the county health department of the county
where constructed.
Form GW-1 '{•>Noith Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22-2016