GW1-2022-09369_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-D For Intemal Use Only:
1.well Contractor inforEORHFOW (�
14.WATER ZONES
Well Contractor Name FROM TO aBsCRIPnON
"7) G & G ft.
NC Well�ctor CertificatioaNumber �� � �' � `/�' v
Well
' �• /� II&JO TEK'CASING' �miittt ed`._ - 0R`LINBR cable
VV W /� L,ILI�� -S / { FROM TO DIAMETER THE MA
�� ft. ". III.
Company Name
L_ �O r I6 INNBR CASING OR TUBING400111
2.well Construction Permit#: mom TO DL►MSrER TMCKKEss 1NATMAL
List all applicable well consowcdion permits(I-,.UIC,County.State,Variance.etc.) ft. ft. in.
3.well Use(check well use): R' R' in.
water Supply WeII: .=17.SCREEN,,
FROM TO DIAMETER SLOT sm I nncKNSSs ER MATIAL
Agricultural E3MungipipaMblic 0 ft. tt. in.
Geothermal(Heating/Cooling Supply) esidemial Water Supply(single) & %
Industrial/Commercial E3Residential Water Supply(shared) AL GROUT
Irrigation - FROM To TERIAL EMPLACEMENT OD&AD40
Non-Water Supply Well:
:-)Monitoring DRecovery ft. %
Injection Well:
it. ft.
Aquifer'Recharge 13GroundwaterRemediation
Aquifer Storage and Recovery DSalinity Barrier FRO ANDIGRTO PACE MA�Le Eimer Aca N i MErsoD
Aquifer Test [3 Stomtwater Drainage
Experimental Technology 13Subsidence Control fL fL
Geothermal(Closed Loop) DTracer 20.DRILLING:LOG attach additional sheets if
Geothermal ing Return) Other lain under#21 Remaftcs FROM ft. ft.
TO DESCRIPTION(color, sorb ck do
4.Date Well(s)Completed: 4 'WeH ID# M fL
Sa.Well Loiation: fQ fa
ft.
Facility/Owner Name Facility Mo(if applicable) ft. UCT 1
� b ��� • P �- �, s� �-vI,III ft. fw
Physical Address,City.and Zip a/0L f
Rackl nshC/nn 7c'ltcl (n(JS7 21.REMARKS
County Parcel IdentiScazion No.(P]N)
5b.Latitude and longitude in degrees/mmaGes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
L y v
6.Is(are)the well(s)V�ent or OTemporaly Si o Certified well Contractor Date fff//h��
By signing this form,I hereby cerdfy th well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: w es or 13No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well miner.
repair ututer#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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: 11 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: tT � (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells List all depths 1f different(example-3@2(10'ay
annd>2®100) construction to the following: j
10.Static water level below top of casing: -1 (fL) Division of Water Resources,Information Priming Unit,
If ivater level is above casing,use"+" , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Infection*Veils: 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: (aj/�`/ construction to the following
(i.e.auger,rotary,cable,direct push,eta)
Q -T .
Division of Water Resources,Underground XWection Control Program,
FOR WATER SUPPLY WELLS ONLY: (� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' _Method of test:`� A 24c.For Water WRI11&Injection Wells: In addition to sending the form to
the addiess(es) above, also submit one copy of this form within 30 days of
A
13b.Disinfection type: T Amount: 6 C)V 'ieS completion of well construction to the county health department of the county
where conswcoed.
Form GW-1 North Carolina Department of EwAronmentel Quality-Division of Water Resources Revised 2 22-2016