GW1-2022-08340_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informa
t
ion
:l
14.WATER ZONES -
Well Contractor Name FROM TO DESCRIPTION
ft ft
r-P,4
NC Well Contractor
LCertification
,JNumber �I I&OUTER.CA$ING:rticmlim4&1sw*e 'OR'GIIVEK' a ucsDie
FROM TO DIAMMR TmCKNFSS MATERIAL
ft. Lj ft. Z_f in. (�� ��
Company Nine 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit : 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 I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public C ft ft. iID•
i Geothermal(Heating/Cooling Supply) sidential Water Supply(single) fL IL in
Industrial/Commercial E3Residential Water Supply(Shared) 1&GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft (p 3 ft S60 I&
Monitoring ORecovery ft It. - 30of bs
Injection Well:
ft. ft
i'AquiferRecharge OGroundwaterRemediation
19.SAND/GRAVEL PACK(if appllwble
Aquifer Storage and Recovery rlSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
1 Experimental Technology OSubsidence Control ft ft. ---— -- --1
Geothermal(Closed Loop) Dnracer 20.DRILLiNGLOG attach additional sheets ifn
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain sim,etc.
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
6) ft ft (/, �
4.Date Well(s)Completed: g-t y-2,2_--Well ID# �,,/�A `t/ ft. zy ft .
5a.Well Location: ft.
�G•
Facility/OwiierName Facility ID9(ifapplicable) fL ft.
,S I l Z kki f�11e- �`l!IS rld J-K-Ali/t,lI s N( ft. ft
Physical Address,City,and Zip ft ft. Irt;r�(�; y' !1 i'(^,•`•Cv; � {
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one
lat/long is sufficient) 22.Certificatio
u"I�S 57. 21r;t_?02_4 -I
6.Is(are)the well(s)alp'ermanent or OTemporary Sign of Certified Well Co r Date
� By signing this form,I hereby cenify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Q o 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 and explain the nature of the copy of this record has been provided to the well owner.
repair wider#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
9.Total well depth below land surface: J y (ft-) 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 2Q100) construction to the following:
10.Static water level below top of casing: 'Z_C) A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (in) 24b.For Iniection Wells: 1n addition to sending the form to the address in 24a
/ ti above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(Le.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) 6,42_ Method of test: 2 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: Aa completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Eavironmental Quality-Division of Water Resources Revised 2 22 2016