GW1-2022-08320_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: p
1.Well Contractor Information: I
la WATER ZONES
W a FROM TO DFSCREMON
3�'tl 300ft- 3XO n S; C-pm
NC Weil Contractor Ccrtification N=ber
M 15 OUTER CASING for moltirased welle OR LIIVER a ble
TI �1.5 le i� CS Utt I Y I J`I YLA h G FROM TO I THICIOiM i MA
C0"P=y Name 6'
16.MMM CASING OR TUBING thermal closed-too
2.Well Construction Permit#: 3(o " Q FROM TO DIAaW� TUCtovMs MATERIAL
List all oppluuble*vH cnnsbacam permits(i�� 1 C.Cowdy,State.Var=m etc.) 1L 1I. 4 m
3.well Use(check well use): ft ft, m
Water Supply Well: KFRTO DIAMETER SLOT s17S TH[C�34 MATERIAL
'cultural DMwicipalftblio Geothermal(lleating/Cooling Supply) IRResidential water supply(single) RI.&.fi iwcommercial DResidential Water Supply(shared) T
'nn TO MATERIAL EOQLAC MEM METHOD do AMOUNT
Non-Water Supply well: /0 ft' 3 G11Y�f V✓ti D Monitoring []Recovery -3 ft- p � f Pc[
Injection Well: []Recovery
DGrurmdwater Remediation
19.St►PUNGRAVEL PACK a cable
Storage and Recovery DSalinity Barrier FROM TO MATERIAL f I EMPLAC MNTMEMOD
DAquifcr Test DStormwater Drainage R R
Experimental Technology DSubsidence Control ft. R
Geothermal(Closed Loop) []Tracer 7&DRII.LING LOG attach add:eiouW sheets if necesea
Geothermal(Heatmg/Cooling Return) Other(explain under#21 Rc arts) mom To DEscR>pIt oN oator watroek ` .�use
C, o n. �C0 D /
4.Date Well(s)Completed: aq a�- Well ID# 3("-7 I .�b y 0 R'fL
3✓Uw r. S�c�;w r w Pt9 c{G
5a.Well Location: b B �.Z IL
F /OwncrName FacrlityUM(dapplicable) f3 R
3A)-3 /�cri /��Q- R tt tt.
Physical Address,City.and Zip ft ft/� :2L REMARKS
l9 ra n v,'1)e DWOMW
County Parcel Identification No.(PII�
!!:I
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
3�0. /FS lf1 N 'Z 403 / W _
6.Is(are)the wen(s)f8Permanent or DTemporary SigoaLue of ed WeA Convactor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordmrce
7.Is this a repair to an existing well: Dyes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constr ninon Standards and that a
Iffim a a repair,full out brown well construction aubrmahon and explain the nature ofthe copy ofdus record has been provided to the well owner.
repair under 421 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 i
9.Total well depth below land surface: (fL) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list aAdgdu if drderent(esmnple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (M) Division of water Reaoitrces,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Man Service,enter,Raleigh,NC 27699-1617
IL Borehole diameter: (ten.) 24b.For Iniection wens: In addition to sending the form to the address in 24a
�9 2 above,also submit one copy of this'form within 30 days of completion of well
12.well construction method: A 1 R D/ y construction to the following:
(i-e-auger,-tars:cable,dirwpush.ato")
Division ofwater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: `� 24c.For Water Supply&Injection Werra: In addition to sending the form to
/ the addrevs(es) above, also submit one copy of this form within 30 days of
136 Disinfection typed OGrL 0 L Amount: �� a Z completion of well construction to the county health departrnent of the county
where constructed
Form GW-1 North Carolina Department of Bnvnenmsnol Quality-Division of wale Resources Revised 2.22-2016