GW1-2022-07457_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GIN-1) For Internal Use Only:
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1.Well Contractor Information: ,\
!_!�!(/.yy. �)/✓J�?�r�� (6s6z-Ae {Jr,1 J,1a 14.WATER ZONES Well Contractor Name 7 FROM TO DESCRIPTION
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NC Well Contractor Cenilicotion Nun)hci 15.OUTER CASING for multi-cased wells OR LINER if a lieab e) _
FROat TO DL��I ISTF.R THICKNESS hIATERIAL
Company Name .
�.�(p 16.INNER CASING OR TUBING eothermat closed-lGo
2.Well Construction Permit#: t?r_ O 1-0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable rrrll carrsuvctian pernuts ti.e Lt/C.Count.State.°jnrionce.err.l ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water-Supply Well: 17.SCREEN
FROM TO DI.ANIETER SLOTSIZF, THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating!Cooling Supply) DResidential Water Supply(single) ft ft in,
lnduStrial/Commercial DResidentirti Water Supply(shared) 18.GROUT
'Irrigation FROM TO MATERIAL El PI Av &AMOUNT
Non-Water Supply Well: ft. fr• a / V
Monitoring DRecoveiy n. ft.
Injection Well: ft. ft. ---AUG t
Aquifer Recharge DGruundwater Remediation
19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery ❑salinity'Barrici FROM TO MATERI j r ,7P1.: T METHOD
AquiterTest ❑IStormwalciDrainage ft. ft. �.
Experimental Technolog,, QlSubsidence Cuntlul ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessarY) �
Geothermal(Heating/Cooling Rctum) Other(explain under 921 Remarks) I
FRO6I DE To SC1t1PI-ION(color hardness,soi Vroc6 t)pe,&�;V vtze_etcc))
ft. ft. -
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4.Date Well(s)Completed:7' �'�Z Well ID#S.�,D- 3 u 7 ft• ) �i rr• /� jG,�� �, ���
Sa.Well Location:
oiire r ��%,ffe'o y lee S ft. -� ft.
Facilay/Owner Name Facility ID11(it applicablci ft. rt.
Physical Address,Citv,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) e� .>rE/ �(.�t( G i,+�U+�EcL(.tJ. �c4�e G�•+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,C-ie,SA-' 4 I•G_ LL"e
(if well field,one latllung is sufficient) i O .r- FWCe-, op e/.�'COS+ N✓u�.� +fJN
22CJert�ificat�/nf�
6.Is(are)the well(s)OPermanent or STemporary Signature ol'Certified Well Contractor 1,le
Br signing this fiuut. /herebr ce,ti/i�that the err//Lsr"'as hrerei Constructed it,nrcmdan�e
7.Is this a repair to an existing well: [DYes or FANo "ith/5A NCAC 02C.0100 or 15A,VCAC 02C.0200 lVe/l Consoucihat Standard..,and that a
l/this is it repaujill out knmrn hell(rnt,ctt'ut tine inlormolmn uurl,nvj!:ria the norurc o/dr, Copt ufthis record has been prooided to the"ell art ner
repair under 421 renmrks section w on the buck of th A loan.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same )'on may use the back of this page to provide additional well site details or well
construction,only I GW I is needed. Indicate TOTAL NUiN1BIiR of'\vclls construction details. You may also attach additional pages ifnecessarv.
drilled: _.__. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9S. (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudliple mel/e list all depdr.s ift i/loent ie.cample-3(t,200'and:'rti l00•) construction to the following:
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10.Static water level belmr top of casing: 2 !!r.-_ (ft.) Division of Water Resources,Information Processing Unit,
If outer level iv ah,we rasing.a,c"t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the fimn to the address in 24a
above, also submit one copy of1this fora) within 30 clays of completion of well
12.Well construction method: conshUction to the following:
(i.e.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 Sunaly & Inie`tion 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: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of 6nvironmcntal Quality-Division of Water Resources Revised 2-22.2016