GW1-2022-08334_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: \/
�,rr� �V `1\� J 14,WATER ZONES
Well Contractor Namel FROM TO DESCRIPTION
Oft. a ft. '/1 l�q San
A .
1 �{ A—
N
C
NC Well Contra or Certification Number i \ 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable
1 1�` FROM TO DIAMETER TffiCKNESS MATERIAL
J 1 1/` i ft. DO ft. � in. 4,� (N L
Company Name ,
16.INNER CASING OR TUBING cothcrnral closed-loop),.
2.Well Construction Permit#: t�Q\ct ` VZ FROM TO DIAMETER THICKNESS 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.
Water Supply Well: 17..SCREEN.:
FROM TO DIAMETER SLOT SIZE THICKN
,ESS MATERIAL
_;Agricultural JResidential
unicip al/Public
Oft. a it. 9, in' �a `I.0
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
__ Industrial/Commercial Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. °?o ft. � �� `i 50 1r�
(-Monitoring Recovery ft. 01 ft.
Injection Well:
ft. ft.
Aquifer Recharge rl Groundwater Remediation
19.SAND/GRAVEL PACK(if n' IIcablc
Aquifer Storage and Recovery 01Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer TestIStormwaterDrainage ;)o ft. ft. # a
Experimental Technology ®ISubsidence Control ft. ft.
(-Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets if necessa.
[)Geothermal(Heating/Cooling Retum) IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,eta)
i O ft. ft. DESCRIPTION
5-D'1
4.Date Well(s)Completed: l 1 2� Well ID#
Sa.Well Location: 1
�\o`�er - 1�, ft. ft.
Facility/Owner Name C c1V/F�acciilliity ID#(if applicca�b(le) Y11�(�/� ft. ft.
lo�] ,J�(t�>�� 1 1\1 ,L�h I�Sa. r/�OJ t ft. ft.
Ph sicaI Address,City,and Zip ft
' n . ft.
N1 �\\m�e CA
'(Vca"� �E' 0—X 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
V!
( /}1� /J '7:'"' �,�F'i1'•J..�.�..,',
0 IILI t V `� N 1 V O ✓V t 1\t W
6.Is(are)the well(s) IOermanent or IOTemporary Signature of Certi Well Contract Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or 00 with 15,4 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 ojthis 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200t'and 2@100� construction to the following:
10.Static water level below top of casing: l (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+f" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1`Yn (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
� n above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: (\ YO 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: 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: f 1 Amount: `/ completion of well construction,to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
. I