GW1-2022-08312_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co`ntranctor Information:
L&tr r y kJbd V 14.WATER ZONES
Well Con actor Nam FROM TO DESCRIPTION
SW
NC Well Contractor Certification Number 15.OUTER.CASING for inulti-cased.wells 0I Ll R,III a 'licable
FROM TO DIAMETER TffiCKNESS MATERIAL
ft. fL in. "�^ eJt1 V�
Company Name V
16.INNER CA NG OR'TUBIN", `eothernial'closed-1oo
2.Well Construction Permit#: ll- I FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,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 OMunicipal/Public /J�r) ft. ft. in; i S yt�
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial _''Residential Water Supply(shared) 18. -
_ h7i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O
Monitoring ORecovery ft. ft. r
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a` licablc
Aquifer Storage and Recovery E]ISalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test I Stormwater Drainage OC© ft. 2 LP ft. � b .Sand Y
�7
Experimental Technology n'Subsidence Control ft. ft.
(bGeothermal(Closed Loop) (]ITracer 20'.DRILLING LOG(attacli additional sheets if ri&iissa )'.
FROM TO DESCRIPTION(color,hardness,saillrock ty e, rain size,etc.)
_�Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ft. ` ft. 1
4.Date Well(s)Completed: 1 �1 Well ID# ft. �, ft.
5 Well Location: r ft- A4 ft-
��' /WYAC:�h W6 ft. ft. E>
r Ja
Facilil //Owner�N�a6me'^ /� �`►��`/i� Facility ID4(ifapp`liicable) ft. ft-
Physical
Phys�icaal'}Address`,/-City,and Zip ft. ft.
.J�✓�YYI\JJt�iY 1 �'LI G��� 3 �0 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell�field,one 1lat/long is sufficient) 22.Certification'
N
6.Is(are)the well(s) Permanent or QlTemporary Signature of ified Well Con for l Iiat
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: ElIYes or No 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 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: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@2000'`and 2@100') construction to the following:
10.Static water level below top of casing: o (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"++" 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: G` IMrin 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: u 24c.For Water Supply&Iniection 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: q 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
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