GW1-2022-07916_Well Construction - GW1_20220823

l i u it i V i i i i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'pay d Cook 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4yA 5 - A 2 J IL IS r
NC Well Contractor Certification Number 15. UTER CASING for T!11=seit wells OR LINE if a ticable
y'1 �QO`K5 ��� �1 FROM TO DIAI1fETER Ti R ICKNESS MATERIAL
y O ft. t It. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I17ATERIAL
List all applicable welt construction permits(i.e. UIC.County,State,Poriance,etc.) ft. ft. in.
3.Well Use(check well use): tt, ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
NAgricultural E) nicipal/Public j ft. ,?it.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial 01kcsidential Water Supply(shared) 18.GROUT
� Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 7
( Monitoring DRecovery
Injection Well:
Ct. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainageri 6L
Experimental Technology C3Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
__ FROM TO DESCRIPTION(color,hardness soiltrock type, rain sir etc.)
Geothermal(Heating/Cooling Return) (�(��Other(explain under#21 Remarks)
4.Date Well(s)Completed: " " Well ID# ft. �� ft.
,.Well Location: S ft.
J Q`m 111D►/�� u��.� / ft. e/ ft' G ej AIJ r 2 ., 2022
Facility/ r Nam Facility ID#(ifapplicablc) �j ft. /- ft. S G3'
,:� Unit
�1 � m��► RVi ►f Q/ �r�fat�oo
Ph sical Address,City,and Zip ft. ft.
66 w 21.REMARKS
County ! l. Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification'
W kg.
6.Is(are)the wells) Permanent or Temporary Signature ofCertificd Well Contractor Dat
By signing this form,I herebt•cert fi,that the nrll(.$)ivas(were!constructed in accordance
7.Is this a repair to an existing well: [3Yes or 'o will,15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nmure of the copy of this record has been provided to the well owner.
repair tinter#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of-.vclls construction details. You may also attach additional pages ifnecessary.
drilled: /V SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / / (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ioells list all depths ifdierent(example-3@200'and 2@10�0''))/ constntcti6n to the following:
10.Static water level below top of casing: / (ft.) Division Of Water Resources,Information Processing Unit,
If hater 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
12.Well construction method:
above, also submit one copy of this,form within 30 days of completion of well
�" !
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 Supply&Infection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
I at. n;�;s�t;��r.,..o• (a�i A m....,,r• C_' completion of well construction to the county health denartment of the county