GW1-2022-09305_Well Construction - GW1_20221006

RECEIVED f
SEP 2 g 2022
Well Contractor Name SEP 2 8
20.2
NC DEQ/DWP
N U�C Central p e !VC DEQ ft. fr.
NC Well Contractor Certification Number
Central 4A.4bTER CASING for mulct-cased wells OR iNER if a livable
e .�+ TO DIAMETER I : THICKNESS MATERIAL
Company Name d R � pin t C,
16 R CASING OR TUBING thermal dwerW
2.Well Construction Permit#: Oj FRO To DIAMETER: THICKNESS MATERIAL
List all applicable well cansn•nrtion permits(i.e. UIC,C•ormm,State,I'arionce,err.) ft• fL fn.
3.Well Use(check well use): fr' fr' in,
Water Supply Well: 17.S BEEN
Ppy.—. FROI TO DIAMETER SLOTSI%E._. THICKNESS __MATERIAL _.
Agricultural MunicipaUPubtic
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. fr. in.
industriaUCommerciaT 9IResidential Water Supply(shared) 18. ROUT
Irri ation FROM TO MATE IA I. F.MPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft tit. a �TrDjjfq- 445aa5r
Monitoring 1311ecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
FRO t TO DESCRIPTION(color.hardacs%solUrock e, nin size,etc.)
19.S *4DiGRAVEL PACK If a ieeblc
Aquifer Storage and Recovery Salinity Barrier FRO I To MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stomtwater Drainage ft., ft.
Experimental Technology 13Subsidcnce Control ft. ft.
Geothermal(Closed Loop) OTraccr 20. RiLLiNG LOG attach additional sheets if tie
Geothermal(Heatin Cooling Return)
Other(explain under#21 Remarks) ft. t ft.
4.Date Well(s)Completed: +��^�^�Well M# ft. t ft.
5a.Well Lticatio fr' �6
n5) then n P_ I n. it.
Facility/OwnerName Facility iD#(ifapplicablc) ft. fr.
:•,-.-,fin.«'"
nPhysical ddress,City,and Zip i� i fr. ft.
21. MARKS
County Parcel Identification No.(PIN) t-
In
Sb.Latitude and longitude in degrees/tninutes/seconds or decimal degrees:
017well field,one lat/long is sufficient) 22.Certification:
c t
N W _
6.Is(are)the well(s) Permanent or Temporary Sig urc ofCcrtiticd Well Contractor Date
1 Bra ring this,forin I herein certili•that the wrfl(s)nrct(were)consn e•ructed in acordance•
7.Is this a repair to an existing well: ®Yes or No airtr Sn Ncac n2c.oleo ar Ise n'C.dC 02C..0200 Well Cnr6stlYl<'tlMi Standards and that itif this is a repair.Jlll nett known wit consirucrion infnrmadnu gnd 4Utlain the native of the ¢I/Iris record has been provided in the aril omwer.
repair under#21 remarks section or on the back of•this form.
23.SJite diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay use the back of this page tot provide additional well site details or well
construction,�nly I GW-1 is needed. Indicate TOTAL NUMBER of wells cons etiorl details. You may also attach additional pages if necessary.
drilled: UB ITTAL INSTRUCTIONS
9.Total well depth below land surface: W lJ! (ft.) 24a.IFor All Wells: Submit this form within 30 days of completion of well
Pnr inultiple sm/b list all depths i(different(example-3(W00'and 2!ir;I00q consouction to the following:
10.Static water level below top of casing: ZCJ (ft.) Division of Water Resources,Information Processing Unit,
1 f urirer level is above coxing.use"��+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U! (in.) Fo 24b. r Injection Wells: in addition to sending the fern to the address in 24a
abov�,also submit one copy of this',form within 30 days of completion of well
12.Well construction method.-- r i r - -
t c auger,rotary, cons ction to chi fallowing:
( .au. g tary,cable,direct push,etc)
I Ilvisjon of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Ceriter,Raleigh,NC 27699-1636
7
13a.Yield(gpm) Method of test- \ 24c.IFor Water Suggly&Injection Wells: in addition to sending the forat to
-� the r ddress(es) above, also submit lone copy of this forni within 30 days of
13b.Disinfection type: Amount: J� completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Envirunniental Quality-Division of Water Resources Revised 2-22-2016
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