GW1-2022-07546_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onbr
1.Well Contractor Information:
1it0/2. S� ,14.WATE ZONES,Well Contractor Name FROM TO DESCRIPTION i. .
Z 3 =A. /y iL e s- 5q-�-/
NC Well Contractor CeniftcationNumber /?SR Sic no
l 1S::0UTERCASiNG f6rniutticsieII:iretls ARtI:1NER`tf'-"litiabli g.`- z: ?
4.I�I�r/. i�/LI,� t .f.�: FROM TO DIAMEiER.' TAICiQdESS MATERW.
Convoy Name fL ... Z- ltaA 5e Yo
2.Well Construction Permit#: fWs a O'�u � Ia:INNER cAs1Nc vR�TUBING �tiit�rt�l�l�edl � -�,_ .
i9n/_`p� FROM TO I DtAMEM TMCKNM MATERIAL
list a!I applitable waA crourtrtection permits�.e U14c,Calmly,stak varianmylcT R fL is
3.Well Use(check well use): n. & I In
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER sLOTSIZE 'nIWKNMSS KATERIAL
OAgrieultural OMtmicipaUPublic 9�'L / in. `v SGi+ y, �L
[]Geothermal(Heating/Cooling Supply) Olkesidentiai Water Supply(single) ft. J f. in
Olndustrial/Commerciai []Residential Water Supply(shared) 1,111i GROUT: •� ry '
0hrigation OWdIs>100.QOO GPD FROM TO MATERIAL EMPLACE:HENT XWMOD&j AMOUNT
Non-Water Supply Well:
OMonitoring ORecovery QR• R lOrJCte �a ��S
Injection Wall: 2.
ft. M
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERW. EMPLACP.iNEPir MEMOD
OAquiferTest ❑StormwaterDrainage 01ko
OFxperimcatal Technology OSubsidence Control fL R.
OCreothermal(Closed Loop) []Tracer 20..DRiLi tNG,LAG`tiitaehAddido`mistieefslf n �.>" C.
OGeothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardam sa ttvra tipt,Vain Size,eta ;A
4.Dato Well(s)Completed: i Well IDk R
Sa Well Location R fL .. .
Facility! wrierNnme FlicilitylDf(if applicable) R' R• lil�ttiofrfi14fi; 1 i�f`^'9
ydt`?D �Cff7tA _ St �.e ( it, it.
Physical A�dfdncss�City,and Zip rL fi.21.'REMARK3e a - a
County Parcel Idemifrcation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hdlong is sufficient) 22.Certifies
.27' Sid `' N
12- ' S"Z e, w ,
.._ 22 •
6.Is(ore)the well(s):,Permanent or OTemporary SiXg
ntraetor I
thk form! Datatf
hereby certify that the wel!(s)was(tune)eorrrtrttUed Imaccordancewith
7.Is this a repair to an existing well: Oyes or W0 Co2C 7100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
tjthk is a sepals,fitl out b+oKm iwril oonsovction.Information and opfaln the mature of the ofthis record has been provided to the tt W owoer:
repair under 021 remarks section or on the back ofthis jmm.
i. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop'Ceothermal Wells having the same You may use the back of this page!to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over+in Remarks Box).You may also attach additional pages if necessary;
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l � (fC
Far mufrfple tvelk list all depths ljd�emit(example-3@200'and 2Q1047) ) Submit this GW-1 within 30 days of well completion per the followings
10.Static water level below top of casing: .7 5, ( ) 24a. For All.Wells: Original "form in Division of'Water Resources (DWR),
If water level k abm'e coring,use-+' Information Processing Unit,1617 MSG,Raleigh,NC 27699-1617
/2 I .
11.Borehole diameter y�/ - (in.) 24b.For Injection Wells:Copy tot DWR,Underground Injection Control(NC)
` Program,.1636 MSC,Raleigh,NC 27699-1636
IL Well construction method: lR�l W e-` rO�YS 2qc For Water Su t and Open-Loop Geothermal Return Welts:Copy to the
(i a nuger,rotary,cable,direct push,etc.) J county eavtronmetrtai heal department o the county where inataIIed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing Ol'er 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,! 1 MSC,Raleigh,NC 27699-1611
I3a Yield(gpm) rp D 1ltethod of test A t lL
I3b.Disinfection type: Amount:__ 1f1 U-
Form Gvv-1 North Carolina Departtamt of Eminnnmental Quality-Division of Water Resources F Revised 6-6-2019
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