GW1-2022-09382_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
��' In Y1 j`1 >14.:WATERZOPM,
e FROM TO
Wll Contractor 2 DPSCRiP1[ON
3 0.214 -4 .I SS�ft ft. �r1
NC Well Contractor Certification Number ----- -' ^-
`iS:Ot7I`ER`CASnVG` ormnni-ca'�I;wells'OR'L'INEIt"-,a`licadle ""_
W c--r ' ii i LG� FROM TO DIAMETER THICKNESS MATSR[AL
t/LJ dS 0 /0 R• f'p: in.
Company Name /� M IMYER-CASING OR TUBING- eotliermat dosed400
2.Well Constriction Permit#: G ) -0Q!77.y�=j 62) FROM To DIAMETER TH1000M MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. ft. I
3.Well Use(check well use): ft ft-
in.
Water•Supply Well: FROM SCREEN TO DIAMETER SLOT SIB TEIICKNESS MATERIAL
Agricultural Vmid
al/Public 0 % Igo ft. in • 0� s y0 Jp�
Geothermal(Heating/Cooling Supply) emial Water Supply(single) ft. ft. in
_ Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
Irrization FROM TO MATERIAL EMPLACBMENTMEMOD&AMOUNT
Non-Water Supply Well: 11, J AKIL 3 "
Monitoring Recovery M ft.
14ecdon Well: ft. M
tmn
Aquifer Recharge DGroundwater Remediation
.19s SAND/GRAVEL;EACK'itapplicablii
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft' 1 ga ft' &^AJ dhe r
Experimental Technology DSubsidence Control ft. M
Geothermal(Closed Loop) Tracer 20-DRU:LMG'LOG.attach additionalsheetsaf-.
Geothermal ling Return) LjOther(explain under#21 Remarks) FROM TO DFSCREMON color hard» -111 k etc-)
ft. ft loil-erkrCYco,
4.Date Well(s)Completed: 9-7- 2i2-Well ID# M ft. -44
Sa.Well Location: ft. 90 ft- 5e,4 4'4e cje
9-Cd A�l AD ft. ft.
v
Facifity/Owner Name Facility M#(if applicable) ft' ft.
Physical Address,City,and Zip
21'REMARK$:
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(ifweli field,one lat/long is sufficient) 22.Ce ti
,'S.3► ` ZSUN 79°!3 S'S• LI/132 w
6.h(are)the weU(s) rmanent or Temporary Sipatae of Certified Well Con or Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an ekisting well: Dyes or E&`V with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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:
S.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 I 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 depot below land surface: 1 SQL (114) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tQt 200'and 2@100) construction to the following:
10.Static water level below top of casing: 7�� (ft.) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- (O (in.) 24b.For Iniection 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: (1C r2Ze.r construction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground Nection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ fQ —Method of test: &149 W#-% %24c.For Water Supply&Infection Wells: 1,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: 8 Dv'n-t=Lj2 completion of well construction p the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEavironmental Quality-Division of Water Resources Revised 2-22 2016
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