GW1-2022-08991_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW 11 For Internal Use 0111y:
1.Well Contractor h`brma
WellConhactoorrName FROM TO DESCRIOMON
�� ft %
NC Well Contractor Certification�Number
�'k,�e k\ \` "1 1 c FROM TO DLtMETTER TJHCKNESS MATERIAL
• � fr. n � I br. .
Company Name
2.Well Construction Permit#: FROM TO aIAMETER TWOMESS MATERIAL
List all applicable dell construction permits(Le.UIC,County,State Variance etc.) % i hr.
3.Well Use(check well use): J• it. I ' in.
Water Supply Well: FROM TO DL METER SIM SIB TH[CENEss MATERIAL
Agriculturd =13M ' aUPublic ft, & 11L
Geothermal(Heating(Cooling Sw1y) ttal Water Supply(ogle) ft. ft. 11L
lndustrial/Commencial Residential water supply(shared)
FROM TO MATER AL EMPLACEMENT METHOD&AMODNT
NuJFL ft.
n-Water Supply well:
Monitoring Recovery ft. ft.
injection Well:
ft. tt.
Aquifer Recharge OGrrnmdwater Remediation
Aquifer Storage and Recovery DSslmityBarrier 77fL
MATERIAL' EMnACEMMMETROD
quiferTestRJA
xperirne�l Technology 13Subsidemce Control
Geothermal(Closed Loop) OTracer ��m
.4� t FROM TO I:RIP710N arobr soalroek etc
Geothermal eatin Conlin Retain Other tier LRetriaika
4.Date Wells)Completed: , ��Veu m!1 q F P 1. Q 2022
Sa.Well Location: U n 9', ft. ft..05
`
SOOG ft.
F� yl �' F-Ity lD#(ifopplicable) . R'
>t fti
Ph,
Address,City.and Zip fL fr:.
Comty Parcel Identification No.(PIN)
5b.Latitude and longitude in degraWrolnutea/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.C cation:
N W I `7 o c'�
6.Is(are)the welts) Permanent or Temporary Signature ofCartified well Co, r D
By signing this form,I hereby certify that the x+ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If tbls is a repair,fill out known well construcams infarXatlon and expWn the nature of the copy ofthis record has hem praWed to the well owner. _
repair under#11 remarks section or on the back of this fornL 23.Site diagram or additional well details:
8.For GeoprobeM.Pr 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 construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land unifies: ID
(�) 24a•For.All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths tfdf jerent(example-3®200'and 2@1001 construction to the following:
rr^^ Q •
10.Static water level below top of easing: y OL) Division of Water Resources,Information Processing Unit,'•
Ifxnter level is above casing,tee"+' 1617.Mafl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (l 24b.For[niection Wells: In addition to sending the form to the'address in-24a
-��Y above,also submit one copy of this forts within 30 days of completion of well
1L Well construction method: construction to the following.
(Le.auger,rotary,cable,directposb,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY T
ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
. W I 13a.Yield(gpri Method of test: 24c.For Water Suaniv&Iniecti f IiWells:-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: completion of well construction tom the county health department of the county.
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resomnes Revised 2 22-2016