GW1-2022-07456_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
WATER ZONES
FROM
I
FRUNI TU DESCRIPTION
Well Contractor Name
2 S ft' S-� ,rx.h
ft. ft. S✓r'1�;Li�. �' (.'� Fes!"'
NC Well Contractor Certification Number 15.OUTER CASING for could-cased welts)OR LINER if a 0eable)
FROM TO DIAMETER 'THICKNESS NATERIAL
Company Name _ /, 16.INNER CASING OR TUBING eotIt I closed-loop)
2.Well Construction Permit#: �� ✓�r �UV FROM ft. TO ft. METER THICKNESS \tATF.RIAI.
List all applicable well construction permits(i.e. U/C.Cann(Y.State. I$riam e.etc.)
in.
ft, ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TU DI:INIETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(HeatingiCooling Supply) DResidential Walcr Supply(single) ft. ft. In•
Industrial/Commercial DiResidential Waler Supply(shared) 18.GROUT
h'1'1 ahOn FROM To NIATERIAI ` Ft•1P. GE t I O d AN10Vi\T
ft. ft. �" 9
Non-Water Supply Well:
Monitoring DRecovcty ft. ft. ZQZZ
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/CRAVE(,PACK(if appiic irSiFdwS: r t"'
Aquifer Storage and Recovery DSallnity Barrier FROM TO MATERIAL \ L NIENT NIETHOD—
Aquifer Test DSlormw'ater Drainage
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiVrock type, rain size,Tres
Geothermal(Heating/Cooling Ration) Other(explain under#21 Remarks) 0 ft. 6 R. e& e
4.Date Well(s)Completedl'��'Z.L Well ID# 3�/ G ft' cS ft• �C .�A /��,, t a►-c�.
59.Well Location: 2.
3 ft. ft.
/�-- s s'
/Yt fir- �C�Tllry I>° —
Facility/Otcner\ame Facility IDG(ifapplicable) lrj ft• S(i ft. 0✓r s
3 D S 25- - y S' Hwyb 1 .L QY!o►-4�©•v, /��. —
Physical Address.City.and 71p ft. ft. j
_rVA,-' 21.REMARKS / ny'�'
County Y Parcel Identification No.(PIN) ' ^�^ �.` X,�N�L�.�/
fYrSB�»� �. N�•�b� f/'ervlc� T�Uin.�UGtV/M(JJWe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` �y �•�C Uw t .>- 7
(ifwell field.one lat/lung is sufficient) 22. ertifieatian:
3S_ 'R!33LT3 -0N 'k°- '2-317512-- W /�' _ -7 21'-21.
6.Is(are)the well(s)OPermanent or Temporary
Signature of Certified Well Contractor Date
Ur signing this(r,nn. I herehr certi/i•that dre rye/I/.v was(,revel cm,sirucled in arcorda„re
7.Is this a repair to an existing well: Yes or ONo rrilh 15A NCIIC 02C.0100 m 1 sq A'CAC 02C.0200 Ivell Ca,sovr,in„Standards and dml a
If this is a repair.fill nu/knmr„ der nnuur of Ihr
cola'of this record hus been provided to the well oit ner.
repair under„'1 re,mndta sec Tian ur on rhr ha k of(hs limo,' 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this Bags to provide additional well site details or ttcll
construction,only I GW-I is needed. Indicate TOTAL.NUMBER ol'wc)Is construction details. You may also attach additional pages if necessary.
drilled:_ — SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit,this fonn within 30 days of completion of well
Fbr multiple wells list all depths i/ai%lereat fcwn,ple-36 200 and_'sir 100 construction to the following:
10.Static water level belo\v top of casing: 2 S (ft.) Division of Water Resources,Information Processing Unit,
if wcaer level Is al Cv ca,in,c.uoe" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For Infection Wells: Inladdinon to sending the form to the aiddress in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Tin construction to the following:
(i.c.auger.rotary,cable,direct Push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this tom) within 30 days of
13b.Disinfection hype: Amount: completion of well consu'uct on to the cotmty health department of the count}•
where constructed.
North C':n'ohna Dc P•artmcnt of En,inauncntal Quality-Dit'imon of Water Resources Res iscd 222-201 a
Fonn GW-I
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