GW1-2022-08177_Well Construction - GW1_20220505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information: f
��m�scx� (n t b ScM 14..WATER 7ANEs
Well Contractor Name FROM TO DESCRIMON
NC Well Contractor Certification Number pft. 2� Il��
�'PSOLTI'ER'CA`SING'([ormultl�easc��"weDs`OR�3IiVER�f[a c"hb1e7.�"";"�
es_ ,�^ c 11,1 FROM TO DIAMETER TRICKNFS.S MATERIAL
�Q,(�/l lx..� ' C ft. ft. I ,wl,,'-r, 77
in.
Company Name 16.INNERCASING;OR':TI7BING..'"eo<hermalcbsedaoo}
2.Well Construction Permit#: 1 ..J O FROM TO Dtatl EM T1OCK(14M I MATERUL
List all applicable well construction permits(ie.UIC.County.State.Variance,etc.) ft 3 ft' 2S— 1D S Q 2 p v C
3.Well Use(check well use):
17.SCREEN...,;;
Water Supply Well: FROM TO DIAINEIER SLOT SUE THICKNESS I MATERIAL
Agricultural E3M cipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) midential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18i'GROITf
Itgation FROM I TO MATERIAL EMPIACEMENN I'METHOD&AMOUNT:.
Non-Water Supply Well: G ft 26 ft. q)C irlht v
Monitoring DRectivery tt ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
:.19:Si[ND%GRAVEIsrPAG% :a- ° cable irk �� � .
Aquifer Storage and Recovery Salinity Barrier FROM TO MAIERUL EMPLACEMENT METHOD
Aquifer Test [2Stormwater Drainage ft• ft•
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) DTracex 1DRMLING11 (atiscli tadditianaisheetii`if
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) FROM TO DESCRIPTION color hardness,sollhuck tnw,pain shr,etc.
ft' 1 3 ft' C I a X 6 vcr rxr
4.Date Well(s)Completed: �{ I t4 a- Well ID# !2 ft' OS ft' r A t'�e
Sa.Well Location:
rX Ila�Ct3r
Facility/Owner Name Facility M#(if applicable) ft. M
-Rm k.n% ad. RSme N 'ask 8 ft. ft.
Physical Address,City,and Zip J ft. ft.
Trahsvl��i4 otsls- oe-9'0o8-opc� z>>REMARxs.-; MAY o
County Parcel Identification No.(PIN) ZOz�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: X 1� t mq Q1 i a I'
hti4"'lT"17 111 'P �'f��..•Li1v�Y;:f�1':�
SS 0 1 S' 3-1. 321301 N aL' 3g` 3. 1 V$20`{ W Z = + 14- 93
6.Is(are)the wel►(s) ermauent or 13Temporary tgnamte of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or �Io with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 7� S (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of using: (P C> (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: 11 . 2 (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 weV
12.Well construction method: (a iQ construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Undergrotmd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) , Method of test:o 1�Uf�loft t`Q 24c.For Water Simply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 0In I pt"v'k Amount: completion of well construction to!the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016