GW1-2022-07888_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Vell Contractor Inform?ation: f ` C
lJ0 J 1 V O n 14. ATER ZONES
Well Contractor Name PR M TOI DESCRIPTION
�` ft. ft.
1 4 W C• (P T y�[f�
NC Well Contractor Certification Number
Q 15. LITER CASING for multi-cased wells OR LINER if a licable_ FR M TO DIAMETER THICKNESS MATERIAL
ft. eft. in. fir/
Company Name [ 4
16M. ER CASING OR BING eothermal closed-lao
2.Well Construction Permit#' FR TO TUDI ET AMER THICKNESS MATERIAL
List all applicable cell construction permits(i.e.UIC,COnntr,State,Variance,etc.) I, ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17. CREEN
gricultural �Mwticipal/Public M
FRO
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
A ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18. ROUT
Irrigation FROM TO MATF, IAL EMPLACEMENT METHOD&A11OUNT
Non-Water Supply Well: ft. I
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge n Groundwater Remediation
19. AND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery [3Salinity Barrier FRO 1 TO MATERIAL EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Traccr 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FRO t I TO DESCRIPTION(color,hardness,soivrock type,grain size,etc.)
ft. 1 ft.
4.Date Well(s)Completed:` 1$-e� Well ID# ft /h 1 ft. n
5a.Well Vocation: ft. V fr.
acilaylOwner Name Facility ID#(if applicable)
ft. ft.
Ph siccal Address,
City,�aandp'p ft. ft.
0i1 Ll.I�V l�U 21. MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
_ l
N dp"
6.Is(are)the well(s) Permanent or [ITemporary Siat re of Certified Well Contractor Date
C�j . "1 ig ing this/brsn,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or IN6 1 A NCAC 02C AI00 at-15A NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill not known well construction informaI.. an e,phzin the nature of t a this record has been provided to the well owner.
repair under#21 remarks section or of the back of this form.
23.Site diagram or additional well details:
A.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You I 1ay use the back of this page to provide additional well site details or well
constnuction,rly It GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�Q (ft.) 24a. kor All Wells: Submit this form within 30 days of completion of well
Fa•multiple tt•ells list all depths ifdifferent(example-3@200'and 2(iu100') construction to the following:
t
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:
Ifivater 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 font to the address in 24a
r abovcf 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
r
13a.Yield(gpm) Method of test: 24c.gor Water Supply&Injection Wells: In addition to sending the form to
^ the ac)dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:�{I ' completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Qualbty-Division of Water Resources Revised 2-22-2016