GW1-2022-07992_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
// 14.WATEWZONES
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Well Contractor Name,
rr rt. if 3d MT
T
2,03� ft. ft r 7
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells),OR LINER if a ►icable
FROM TO DIAMETER TH1C14�ESS MATERIAL
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Company Name 16.INNER CASING ORTUBING cothermal closed-loop)
f 3 8 G FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: ft. TO
in.
List all applicable well construction permits(i.e.County.State,Variance.etc.) rt ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculture] ❑M�unicipaUPublic ft. ft. in.
m❑Geotheral(Heating/Cooling Supply) g esidenlial Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation o ft. a ft. ram/
Non-Water Supply Well: - --
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL`.PACK(ii'a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO h1ATEl11AL E\IPLACEMENT METHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology O Subsidence Control
20.DRILLING LOG attacb additional sheets if necessary)
❑Geothermal(Closed Loop) i]Tracer FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,eta)
❑Geothermal(Heating/Cooling Return) /❑Other(explain under#21 Remarks) 0 ft- l 0 11- 11fe d C e''
4.Date Wells)Completed: / —oG ft v ft. J3 ire 6f�t
n ft. .7 62 ft G ..�� �Cc,e Gam,
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5.Well Locafi =��LC ft. ft
L
Facility/Owner Name Facility app o5 ID#(iflicable) ft. q o.
/� ft. 0 fit. Cy
SO -1 !J✓ f t�e_S'f-!�I E�w S GS'E bn lr^i rt. rt. y+ s. la bw;,3;
Phv teal Address,City,and Zip
nn 21.REMARKS''
,LL n C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(irweelll field,one lat/long is sufficient) / �y
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®lVo copy of this record has been provided to the well owner.
Ij'this is a repair,fill out kwo wr well consowction h formation and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use die back of this page,to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total-well depth below land surface: 2690 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nrultipie wells list all depths if different(example-3@200''alnd,21Q100D construction to the following:
e 10.Static water level below top of casing: / U (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use J"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (� (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: R©'f,vt / r/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Jr
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) o Method of test: f 7 /� 24c.For Water SuvPIv&Geothermal 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 3 i/7 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013