GW1-2022-09384_Well Construction - GW1_20221010

2.9
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
70 t*A A4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 1'S:OU1ER_CASING' or`:mtt cas7 d wens'OR LWER -e tieaWe
WArea W Z P D C T�C FROM TO DIAMETER in. THICKNESa MATERIAL
Company Name ,` J
r� ( hh �1 �1 1'6:INNEWCASING�ORTUBING; eoN�rmalclosed-100
2.Well Constriction Permit#: v1 L1� V 7 t.92
` 2 O 2, FROM TO DIAMETER THIC MESS MATERIAL
List all applicable writ construction permits(i e.UIC,County.State,Variance,etc.) ft- ft. is
3.Well Use(check well use): ft' ft' in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIB THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 fL in
Geothermal(Heating/Cooling Supply) residential Water Supply(single) M ft, in.
Industrial/Commercial E21tesidential Water Supply(shared) I&GROi T „
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Weber Supply Well: 0 ft. ft.ta
A
Monitorin Lg Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.3AND/GRAVEL a" tleable . ,
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage zo ft. ' ft. to
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DR�:f.ING"LOG.attach addidonai;sheets it:
Geothermal eatin Coolin Return) 00ther(explain un
der#21 Remarks FROM TO DESCRIPTION(color,hardness,soivfock tym graln dip,etc.
ft. ft. l i t.
4.Date Well(s)Completed: ..�e�'Well ID# ft. ft.
5a.Well Location: ft. I.
REQDcm2
Facility/Owner Name Facility 1D#(if applicable)
z212 PFY1_►'YIE2ST61JE GT. i^J9 ap ft. ft -�
Physical Address,City,and Zip
`21 REMARK$: s
County Parcel Identification No.(P1N) 1
5b.Latitude and longitude in degreed iminutes/seconds or decimal degrees: -
(ifwell field,one lat/iong is sufficient) 22.Ce 'tcati
3�. 5y S'3Ct x ?4, —71°13 t� w �j/, g'-1 --22-
6.Is(are)the well(s)(25ernment or DTemp rary Signa of Certified Well ntra Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: Yes or04
with 15A NCAC 02C.0100 or 15A NCAC 02C 4200 Well Construction Standards and that a
If this Is a repair,fill out known well construction it formation 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:
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 I OW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRIICTIONS
9.Total well depth below land surface: 2 PO (4) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2C3n 1001 construction to the following:
10.Static water level below top of casing: (ft.) Divlsion of Water Resources,Information Processing Unit,
If water level is above casing,use"+^t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 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: g br 199.!4 construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Metbod of test: BLOW .For Water Supply&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: ,t'' completion of well construction'to the county health department of the county
where constructed
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
t