GW1-2022-08283_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For InteInal Use Only:
1.Well Contractor Informatiolln: l/
Y 14.WATER ZONES:
Well Contractor Namel FROM TO DESCRIPTION
t-'\0 -.�)
ft. ft.
sNC Well Contractor Certification Number i - 15.OUTER,CASING for multi-cuscd veils OR LINER(if a "licable
FROM TO DIAMETER THICKNESS MATERIAL
L J V 1�1 l 41 ft. ft. a in. SCSO 40 N
Company Name
16.INNER CASING OR TUBING' etithernwl closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Parlance,etc.) ft. - ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN.
Water Supply Well: .: =
FROM TO DIAMETER - SLOT SIZE -THICKNESS MATERIAL
_)Agricultural Municipal/Public 3'5ft. l 0 ft. a in. 01 a S�q0 ?q(
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.
Industrial/commercialResidential Water Supply(shared) 18-GROUT
_ 1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- o2i�ft. r�om� 3 r
Monitoring E]Recoveiy ft. it. 1 U
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if.d,..licablc
D Aquifer Storage and Recovery __I Salinity Banier FROM TO MATERIAL EMPLACEMENT METHOD
_,Aquifer Test 0 Stonnwater Drainage aC)ft. L10 fL �� r
Experimental Technology FnISubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING'LOG(attach addition3rl sheets if necessfi`)`'.
BGeothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) I
FROM To DESCRIPTION(color,hardness,soiUrock type,grain size,eta)
4.Date Well(s)Completed: 1'` °2�OZ� Well ID# ft Gl ft. Au 0
Sa.Well Location: ft. 19, ft. Q_V0_ ie_ CA
Facility/OwnerIName Facility ID#(if app`lictarble) (� rip 2a ft. ft ' C t
3g s- More Ne.>rri tut Lrx CA, htm I� �0�oGp J ft. c) fL sr-)
Physical Address,City,and Zip ft. ft.
yWm lJ� V! tl l a�J I 21.REMARKS - - - -- - -
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:35D 0 aCia N ` S" Q (U,63S w � , r.t;:,_ �i '1
aT"'I y ,,. 'II- its-ID
;... '
6.Is(are)the well(s)PPermanent or QlTemporary signature o edified Wel ontract64 Date
,,,���((( By signing this farm,I hereby cerlify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd 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: 1�+ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Iv (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@20i0'and 2@100D construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"i+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lX (in.) 24b.For Iniection 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 well
12.Well construction method: VY d (Z b 16 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: Um 24c.For Water Supply&Iniection Wells: In addition to sending the form to
`` y( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r 1 Amount 1/L1 completion of well construction Ito 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