GW1-2022-08988_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only. j
1.Well Contractor Information:
WellCo�racmrNama FROM TO CRIPTTON
I�- & Z It
%0 (A
NC Well Contractor Certification Number
FROM ft. � D� �� S MA•r RLAL
f(
Company Name
2.Well Construction Permit#• �O a a — O O a FROM .TO DIAMETM THICKNESS MATERIAL
List all applicable xdl conduction permits r&e.(I1C,CmaUy,State.Yarimice,eta) % ft. )O'
3.Well Use(check well use): ft
Water Supply Well: FROM TO DIAMETER SLOT SIM TffiC nq= MATERW,
Agdculhud L)M blic ft. it, i
Geothermal(Hmtmg/Coolmg Supply) dcetial Water Supply(single) ft. f 1 .
Industrial/Commercial Residential water Supply(shared)
Irrigation FROM TO MATERIAL METHOD&AMOUNT
xon-Water Supply wen: ft. ft (�oAc Ito Ik
Monitoring Recovery ft: ft.
Injection Well:
ft. fL
Aquifer Recharge 13Grotmdwater Remedistion
Aquifer Storage and Recovery" [3Sal1nity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft' %
I.xperime�l TechnologySubsidence Control ft• ft
Geothermal(Closed Loop) Tracer FROM To DFSCRIMON color,h,rdn rack bw.umin xha6 etc
Geothermal Caolin Retnm -I�irin¢d�#Zl ©
4.Date Well(s)Completed: °2 W7\ Well IpfR ft' ft' --1-� • "
5 Wen f J V a O ft- �'Jf 1i - - yex
Uni, arat fL
Facility/OwnerName FaciilitylD#(ifapplicable) ft.
3�� �o•�o�--rt� . ft. �L
Physical Address,City,and Zip ft. %
County Parcel Identification No.(PR-1) I I
5b.Latitude and longitude in degrees/mtnutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ' 22.CertiB on:
31ra� 1' x � � ° a`dI � � I W
at
6.h(are)the well(s)�Pernment or DTimywrary - - Signahne of Certified well Contractor Date
By signing this form I hereby certify that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or E3No wlth 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Constnurion Standards and that a
lfd&is a repair,fig out brown%+conduction information and a T&M the natra-e of the cepy ofdas record has been provided to the uell•owner
repair under#21 remai*section or on the back of d dsJb m. 23.Site diagram or additional well details:
8.For GeoprobeM.PT 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: Q SUBMITTAL INSTRUCTIONS +I
9.Total well depth below land surface: V ( ) 24a.For All Wells: Submit this,form within 30 days of completion of well
For mul0ple wells list aAdgda j'dVerent ft=Wle-3Q200'and 2®1 M construction to the follo
wing: i
10.Static water level below top of casing: T'J UP Division of Water Resources,Information Processing Unit,
Ifxnter level is above casin&use"+ P _ 1617 Mail Service Center,Ralelgh,NC 27699-1617
11.Borehole diameter: V (In.) 24L For Infection Webs: 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
1L Well construction method: construction to the following.
(Le.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q _ 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: "' t 24c.For Water SnDDIv&Inlecti I 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: 1,lQ'U14 completion of well construction td the county health department of the county
where constructed.
• I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22 2016