GW1-2022-07239_Well Construction - GW1_20220805

±'`WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infformation:
✓l i� l/ U y'l JA:MATERZONES
FROM TO DESCRIPTION
Well Contractor Name ram • ! ft.3 d 2-(4 - 0
NC Well Contractor Certification N er `,IS.OUTER CASING Wor Multi-disedtwetts)OR LINER(if a ieable
p f FROM TO DIAMETER I THICKNESS MATERIAL
V�/ �►' 1 �G��S �1�7�. D ft. ft. I in. _IV PIZ
�y
Company Name 16.INNER CASING OR TUBING eothermal closed•loo' -
2.Well Construction Permit#: FROM' TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft: in.
3.Wen Use(check weft use); ft. ft. in.
1 Well: *17:SCREEN
Water Supply Y FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural riMunicipdUPublic C ft. ft. in.
Geothermal(Heating/Cooling Supply) bilsidential Water Supply(single) R• g• in.
Industrial/Commercial nResidCnfial Water Supply(shared) 18.GROUT '
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. ft. 3/ 4 C�dvr
Monitoring Recovery ft. ft. r `1
Injection Well:
Aquifer Recharge [)Groundwater Remediation
+•19:SAND/GRAVEL PACK if a Eicable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage R• ft.
I Experimental Technology OSubsidencc Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional sheets if n
FROM TO DESCRIPTION(color,hardness%oatrock size,etc
RGeothermal(Heating(Cooling Return) '_ Other(explain under#21 Remarks) R• r ft.
4.Date Well(s)Completed: Well ID# 5 "/ ft. ft. Ste' j�
Sa.Well Location: ft. 6 ft. �v- C>
)^ ft. ft. Cry
Facility/O{�wner Nam �e / Facility ID#(if applicable) / ® ft. ft. � t r'
�f 8 7 U i t 1�L J—`•1 1rCX. �i✓H�J-c f(2 vLY ft. 'i_�f;`i ft. n 7
Physical Address,City,and Zip ft. ft. v
:21.MAARKS - - - -ter
County Parcel IdentificationNo.(PR)
5b.Latitude and longitude in degceesAninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 7, 22.Certification: "
W
6.Is(are)the well(s)OPermanent or emporary Signs of Certified Well Cond1etor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or EIN; with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and expla)n 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 thisform.
23.Site diagram or additional well details: '
You may use the back of this page to provide additiorial well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: ��o (ft-) 24a.For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-4200'and 2@100) construction to the following: '
Lam',
10.Static water level below top of casingit (ft.) Division of Water Resources,Information Processing Unit,
I water level is above casing,use"+" r t;'
f g _ t;��-�.•r 1617,MaihSetpice Center,Raleigh,NC27699-1617 '
11.Borehole diameter: , •.(in:)�-` � - 24b.For Iniection-'W�l1se:=In"addidon 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:.' t^�•f construction to the following:
(i.e.anger,rotary,cable,directpush,etc.) ` ^ Y/f - `•
f Division of V�te�Resources,Underground Injection Control Program,
FDR WATER SUPPLY WELLS ONLY ? r ` d : ''1'6361Ypat1 Service Center,Raleigh,NC 27699-1636
13a.Yield`(gpm) 'i Method of tesW. L J° ©li+�� FAr Watfir_Snunly&Ia7ection Wells: In addition to sending the form to
the address(e`s)'.above alsosubmit one:copy of this form within 30 days of
i° j.
13b Disinfection type:. ��'i Amount+' ( t%t2.�'c e4`� completion o-well construction to the county health department of the county
where constrtcted+
Form,GW-1 t DNorth Carolina Departinent of l3nvironinental Quality Ybrvtsioa of Water Resources i Revised 2-22-2016e'"
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