GW1-2022-09283_Well Construction - GW1_20221006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1../(kWell Contractor Information:
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Well ContractorName U
FROM TO DESCRIPTION
ft. ft.
g 5 y5 A «.
NC Well Contractor Certification Number
C 01 VVA ' i f al✓,J `FROM TO•7fkL3R i.CX`$I1V::?ffot rm.DIAMETER
THICKNESS
p' lleM'aUATERIAL
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Company Name 9 . / 126 tn. 5D/1 zi a>_
[� /�� 1; :GiDACri R1!1]B
2.Well Construction Permit#: J WZ I G LI 6 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft, In.
Water Supply Well: J11R
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) In.
IndustriallCommerciai [Residential Water Supply(shared)hTi 8t10n TO MATERIAL 11 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � ft. e,yl 1' ,t, ILl13CiMonitoring i Recovery it.
Injection Well;
ft. ft.
Aquifer Recharge []GroundwaterRemediation
;�T9` '` / t'i+E�',1'AO Ife"''►foebi z�; +trot. �itiid�_c��s'
Aquifer Storage and Recovery_ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology l' Subsidence Control ft. ft.
41
Geothermal(Closed Loop) [3Tracer c-.0 D L Gr 300;a`ttpe add tti)ii %$eetstifneb" a` ,.. 'vas .
Geothermal astir Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardneu solUrock rain ai etc.
O ft. 3.5 ft. Cla
4.Date Well(s)Completed: Well ID# g 4 n' -305 ft. Y Ct yt I t,
ft. tt.
Sa.Well Location-
Facility/Owner Name Facility IDl!(if applicable) ft. ft.
9 5-7 6 .416 291 6 51, N_ho ft. rL
Physical(Adddres -s,,�Ciity,and Zip
1/0 I t I I
County Parcel Identification No.(PiN) -
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification-
6!H 14 5 N -�r ,aw5ZI W
6.Is(are)the well(s)(SPermanent or Temporary
Signature of Certified Wt l Contrector Date
By signing this,/brm,1 hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or J§No with ISA NCAC 01C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a
1f this/s a repa/r,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 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 some 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: .30 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdVerent(example-3Qa 200'and 1®100� construction to the following:
10.Static water level below top of casings` 100 (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use
d+�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `7 (in.) 24b.For Injection Wells: 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
12.Well construction method: A y 1 tw _ 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) 15 Method of teat: Z 24c.For Water Supply&Infection 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: OY't 11 Amount: 2 C s 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 Watcr Resources Revised 2-22.2016