GW1-2022-08567_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L1 yI w u i a UC4 14.WATER ZONES
Well Contractor Namet FROM TO DESCRIPTION
t Vt� 435ft. �g ft. , �OL'h
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a ticable)
i' FROM TO DIAMETER THICKNESS MATERIAL
y y 1 ft. .3�ft. CA in. 1501
(n (��l Pp
1 r�s QI1 ��I ir�e� t TVV
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#- lJ O - J� 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2Gft. 3V7 ft. f1 in. O Dv�
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. T.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t.
pQLLr
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage a0 ft. 3g ft- #2- fl[_,j
.�
❑Experimental Technology ❑Subsidence Control ft. �e� ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)® ft. ft. © S.6I/(
4.Date Well(s)Completed: 3I Well ID# ft. ft. OI,nd 1 0L
5a..JWell Location: �( {�,, {_ ft' rl ft' *�n
ge-1_ 1J11 I1 M ��tivl « "t�Y�S ! ft. l?) ft. sw"Jd- )-rnnre�
Facility/Owner Name Facility ID#(if applicable) aft- 35-ft-
3 R'
P sricall Address,City,and Zip ft. ft.
21.REMARKSg'-f,L^i='
County Parcel Identification No.(PIN)
MAY 17 2m
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellll(field,one lat/long is sufficient) Q v� 22.Certification:
l 1 9q 334 ,N O L W e n + nr�1'� �Ctl v
✓K Y f�:'I 771if` f•l'� ,Vi 1
-o
6.Is(are)the well(s): 0-rnument or ❑Temporary Signature ofCe6tied Well Con or Date
By signing this form,I hereby certify that the wet/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1�60 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3a0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@t200'and 2@100')
1� (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: LP (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
mn � Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Y Y ,us l�\�t/l✓t 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: i
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
�
13b.Disinfection type: 4 Amount: '
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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