GW1-2022-09334_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Informatiion:
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FROM TO DESCRIPTION
Well Contractor Name ft. ft.
t-15 `/5: ft.
NC .1 -lit R1CrA'S Well Contractor Certification Number ly' z"
. �S f�iittl E � A"1 iU'sue-''� ..�r{�"•
C�, • � 1, „^ I��� _/ v� /'O PROM �ITO �D�TAMZTER� THICKNESS TERIALVl/t'/f (J (— iSo CompanyN af,3 . t s.'
2.Well Construction Permit#:Aggj� 5 W 2_' — 0 q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction penults(i.e.UIC County,State,Variance,etc..) ft. ft. In.
3.Well Use(check well use): ft.
...ems. ;..ram- xL4'
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R. ft. In.
Industrial/Commercial Residential Water Supply(shared) rJ'
I LTi et10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. I y )3,, S
Monitoring 1311ccovery rt. ft.
Injection Well:
:Aquifer Recharge []Groundwater Remediation
i Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage ft. ft.
Experimental Technology [Subsidence Control
Geothermal(Closed Loop) [Tracer 0 s e 'J[-ills e` '• `.�sw. ;t`.':.;
Geothermal eatin Coolin Return :Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardoeu solProek rain sl etc,
4.Date Will(s)Completed:J t�_ Well ID# ): 6 tt. y 0 tt. t
Ss,Well LocetlonE ft. n. ("77
Yr vgLJC"2
Facility/Owner
Name Facility IDN(if applicable) ft. ft. O C T 0 r
2022
Phvsical Address,
,pCity,
,a d Ziip�
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FIA
County ' Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[attlong is sufficient) 22.Certification:
,35,3og'2S N -IYX,0063
6.is(are)the well(s)OPermenent or'[Temporary
Signature of Certified W611 Contractor Date
By signing this form,1 hereby cerl9y that the weil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yea or ®No with IJA NCAC 02C,0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
!*this Is a repair,Jill out known well construction blfornnatlon and explain the nature*of the copy of(his record has been provided to the well owner.
repair under N21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the some
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed.Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ila 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
if water/eye)is above casing,use"+" 1617 Mail Servlee Center,Raleigh,NC 27699.1617
11.Borehole diameter: 17 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
�j above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injectton Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail r Service Center,Raleigh,NC 27699-1636
Method of test: A- - 24c.For Water Suably&Inie ction Neils: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ✓'t VNt_ Amount: 2-des completion of well construction to the county health department of the county
where constructed.
' I
Form G W I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016