GW1-2022-07464_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
/1.IW�ell Contractor Information: /
t/WA �Ir//rMAT�f7���.���/, �lLfLL►t�C� ��ItL(i+1/t'p 14.WATER ZONES l
--y FROM TO DESCRIPTION
Well Contractor Name
Z 5 (t• 5S ro l; � ,•• f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINERTalicableJ 9j FROM TO DIAMETER s THICKNETERIAL
i
Company Name /n 16.INNER CASING OR TUBING eothermal closed-Go
2.Well Construction Permit#: fe r &J-fit ✓L- FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL.
List all applicable weld consmiction permits(i.e.VIC,Countrt State, IV(friance.etc.)
ft. ft. in.
3.Well Use(check well use):
17:SCREEN
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial oResidential Water Supply(shared) 18.GROUT 7
Irrl atlOn ERO111TO MATERIAI, .:\C 'ENon-Water Supply Well: ft.
Monitoring Recovery ft. p,Injection Well• ft.Aquifer Recharge Groundwater RemediationRAVEL PACK if applicabt n Al
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL YN LACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessa
VINITO DESCRIPTION(color,hardness,soil/rock type, rain size etc.
RGeothermal(Hea(ing/Cooling Return) Other(explain under#21 Remarks) tt. It e •4.Date Well(s)Completed:/ - Z'2-2-4 Well I Di�� �✓ / L: !O r le JCS r o I feSaWell Location: lt
S'D ft' G,r, f er r! Y�L SS' rr,
Facility/Owner Name Facility ID#(ifa rlicable)
3 D�� UJ �`f, GaX%/LW `oi✓f /11�� ft. ft.
n. rt.
Physical Address,City.and Zip
✓! / SV /✓ Y21. MARKSTe /t f I J .4 ,Cotmty Parcel Identification No.(PIN) O rA, v_e-I �"'� 0',eV ,l Me t
r .,i✓ ic+- (' ;t� Fro
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification• ro Se1r�L!�
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified WeII Contractor Date
By.signing this fium. I herehr ceriil.v,that the n:ell(s)wax(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or R]No with 15.4 NCAC 02C.0100 at 15A NCAC 02C.0200 Well Cousnvetion Standards and that a
/fthis is a repair.fill oat known well construction information and ecplain the name ofthe cope gfthis record has been provided to the well owner.
repair under#21 renmrks section or on the hack gfthis/brut. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nadtiple wells list all depths ifeli/ferent(ecample-3Li',200'and-'C 1001 construction to the following:
10.Static water level below top of casing: (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 Infection 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: 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suably& Injection 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 G\V-I
North Carol p`
Carolina Department of Environmental Quality-Division of Water Resources Re ised 2-22-2016