GW1-2022-09381_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.well Contractor Information:
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Well Contractor Name FROM TO DESEP-MMON
302�-L l� � l ft.
fL �2 G�'f'n'+
NC Well Contractor Certification Number 13:`Ot1TER'CASIIVG' r molft elased wells`OR'LIIVL�RT a lieahle
♦C' ■ / A I�G /� /-- ` FROM � TO R• DIAMETER in. %[Q'IESS MATBR[AL .
Company Name TL` l' ��( J►�a. . /l�
4' eotbermal closed--too ,v
2.well Construction Permit$: "�0 -n A V b 7 2."�ZJ ETER TIHCICNESs MATERG►L
161NNERCASIN ;ORTUBIIYG;
FROM TO DIAM
List all applicable well construction permits(i e.111C,County,State.Variance,etc.) H. ft. in.
3.well Use(check well are): ft ft hL
water Supply well: FROM E TO WAIMETER SLOT SIZE TIRCKNM MATERIAL
_ Agricultural C)Municipal/Public Q ft. IZ& ft- is
Geothermal(Heating/Cooling Supply) besidentiai Water Supply(single) ft. ft- in
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri 8tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ` ft 3 A O
Monitoring [_Recovery ft. ft.
AQA.0 OE
Injection well: ft
Aquifer Recharge DGroundwater Remediation
;19d:SMiD/GRAVEIS:P,AGK�rf` licalile'
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStornwater Drainage ft• ft•
Experimental Technology DSubsidence Control ft• ft•
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG hash additional:sheetsM-
_
Geothermal eating/Coolie Return) _Other(explain under#21 Remarks FROM TO DESCRIMON color,haudn=6 solVnxk type,main sbft,eta
ft. ft.
4.Date Well(s)Completed: 9-to well EN ft• ft•
Sa.well Location: ft•
2,ctzft.
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Facility/Owner Name . Facility ID#(if appheabie) ft. ft.
2 Z17 PA, ., r tit:llote.) 5�
Physical Address,City,and Zip
1,ka 5ay Vag- 21 REMARH$
County Parcel Idenh�No.(PIN) — -
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce lion:
35 . N 7 9- ?/4A LW
6.Is(are)the well(s)Qf rmanent or Temporary rgn of Certified Well Contra Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or OKo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.For Geoprohe/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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0� (fL) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3©200'and 2©100) construction to the following'
10.Static water level below top of casing. 2S� (ft.) Division of water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Serviee'Center,Raleigh,NC 27699.1617
11.Borehole diameter. (0 L m.
i7—C ) 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: er vI 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) Method of test:,Jft, .For Water SunDav&Injection 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: — Amount: /[�Bwhildt completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016