GW1-2022-07295_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: �
1.Well Contractor Information:
14.WATER ZONES �
Well Contra or Name FROM TO DESCRIPTION
S O H- 71.fm
�5� ) 1?0 n. 200 fL
NC Well Contractor Certification Number
\ 1 I5.OVI'F.R CASING for multi-cased iv OR LINER orap ivable
4 g n d p?w'S AJ Q�1 lr I I �a•, 1 l7(J FROTi TO D fE1�R THICKNESS 1rA 1L
Company Name 4
V.
16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER
2_Well Construction Permit#: ODIAMETERTHICKNESS MATERIAL
Listall applicable irell construction permits fl e.UIC,Cou my State,Variance,etc.)
3.Well Use(check well use): tt' fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE TIIICKNFCC hfATERLIL
Agricultural DMunicipal/Public 0 ft. ft. in.
f .
Geothermal(Heating/Cooling Supply) L&Rcsidential Water Supply(single) ft. % in.
�Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERAL MPLACEMENTAIL-MOD&AMOUNT
Non-Water Supply Well: © it. 3 [t IM
1.Lp a wm
Monitoring Recovery 3 tt. -?,l7 it. lbotqnA Injection Well: - �w e
R. R
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) }
❑IAquifer Storage and Recovery Salinity Barrier FROM TO DIATERLIL E,iiP1ACE1LfENT METHOD
Aquifer Test [3Stor nwater Drainage it ft.
[DExperimental Technology [3Subsidence Control
LIGeothermal(Closed Loop) FITracer 20.DRILLING LOG attach additional sheets irnecessa
Geothermal(Heating/Cooling Return) 00th.r(explain under 921 Remarks) FRODI To DESCRIPTION(color,hardness,soiltrock t)pe,gain sae,etc)
ft. / � It. �r �YZG��
4.Date Well(s)Completed:01 9-0 1 9,0 XL-Well ID# 3 to Q ft I r -kilo
5a--Well Location:p 0 O n- �,$S�ft a cy yt l f e�
IL-Wl 6 r S v- « rt.
Facility/O%werName Facility ID (ifapplicable) H" H'
a,0 - Apt,l Lidoe., tLY10,td56vl, dJ e �?s3-7 rt. it. �; gym.. f �.. ,
Physical Address,City,and Zip tt' It.
\r r
V ox)C� b 3 5t-Q I y t 21.REhiARKS
County Parcel Identification No.(PIIN) �f1�Cf7(ii°ilc^l ft>,Sr1q,n, u
J�'vQr�313G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: t•
3(e . a� � �LQ t-1 N S. �� 1 �� W
6.Is(are)the well(s)JaPermanent or ❑ITemporary Signature of ertified Well Contractor Date
By signing this form,I hereby certify that the well(s)iras(were)constructed in accordance
7.Is this a repair to an existing well: 'E]Yes or SNo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the irell oumer.
repair under 421 remarks section or on the back of this form.
• 23.Site diagram or additional well details:
8.For Geoprobc/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBI4IITTAL INSTRUCTIONS
9.Total well depth below land surface: (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili erent(example-3@200'and 2@100) construction to the following: i
lU.Static water level below top of casing: o (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 2 Q O?'7�e above, also submit one copy of thus form 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,1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 IVIail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) `� Method of test- t)q 24c.For Water Supply&Injection Wells: In addition to sending the form to
((II ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CGYI CuV't Amount: 0 Z completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016