GW1-2022-09474_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
C- 1 l 0 �' Ct 2 P LS 1 14 R!A1ER ZONES ., +_.. _ "
Well Contractor Name FROM TO DESCRIPTION"L � �
I SS -5 b r"
3 541 ft. It.
NC Well Contractor Certification Number ,-WOIJTEWGASING.formolh-cnseil>wells ORsLINER'ifa ' cable =_
\ FROM TO DIAMETER THICKNESS MATERIAL
4�pc1 s��`s t�Qu Dy-t �`, ✓�4 1nC i ft- b l ft- in- Foa l fvL
Company Name
2 _ :16.XMNER'CASINGOR`TIJBING' eothermal'closed-liio`
2.'Well Construction Permit#: ✓�J 7j ?j� FROM TO DIAMETER THICKNESS MATERIAL
fL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc..) ft' I in.
3.Well Use(check well use): M fL m-
Water Supply Well: 17.SCREEN._ .°` = '.._� , _ 4
FROM TO DIAMETER' f SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. lit. in:
Geothermal Mating(Cooling Supply) t@Rsidential Water Supply(single) ft• ft. in
Industrial/Commercial Residential Water Supply(shared) �GROIJTy
irrigation FROM TO� MATERIAL n_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- ft- VL vv, eLQ,
Monitoring DRecovery 3 tI �� ft. �l1.Vh
oe
Injection.Well: -- - --
ft. ft
Aquifer Recharge OGroundwater Remediaticm
19,<SAND/GRAVEI:PACK if a'"licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MA7 F RiAr. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fL
_;Experimental Technology Subsidence Control ft. it.
Geothermal(Closed Loop). OTracer i)iDRILL"ING LOG-"attach additional sfi"ifuecessa
BGeothermal'(Heating/CoolingReturn Other a lain under#21 Remarks FROM TO DESCRIPTION color,hardness,sm7/rock tye, in sae,etc.)
) _ (explain ) fL IL
0 0 � 1
4.Date Well(s)Completed: f 0 0� Well w# fL bQ ft' }�jYD in�v�. _4navwelTk.r' roCA-
5a Weu'Location K;Ce��lj��1r1e�'S i'inC .... .... �0 0: .
a"Ar_1t304.LLX , ;..1�?Ellt�I�bAUfes
FaciWIO,vner Name Facility lIl#(if applicable) ft
t��'b C,���'2rS'bvtcr �-a.lne. �e-�iG��e.✓'St)hi �1c atis3-1 n ft i 6 ZRI
..
Physical'Ad dress,City;andZip ft ft. s 'i^1 + i .G• e'x?a Unift.
Q-Y1 Ce., o31�k-A 0;t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3� 30 912.1 N I '� �. OctS W
6.Is(are)the well(s)f Permanent or OTemporary Signature o ertified Wi I Contractor Date
By signing this form,I hereby certify that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out(mown well construction information and explain the nature ofthe cbpy otthis record has been provided to'the'ibell 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 details. You may also(attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS!.
9.Total well depth below land surface: . g S (ft-) 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;arrd 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources;Information Processing Unit,
If wafer level is above cnsirip'use"+" .,_ 1617,Mail Service Center,Raleigh,NC 27699-1617.
11.Borehole diameter: 24b.For Infection Wells: In addition to sending the-form-to the address in 24a.
:.,
- - - above, also submit one,copy of tliis form within 30 days of completion of well,
12.Well construction"meth'od -'al-fZ K0 TrW0-1 _.....
construction to`the following: r
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
_ , _ Q . . � 1636 Mail Service Center,Raleigh;NC 27699=1636
13a.Yield(gpm) S© Method of test: {\� 24c.For Water Supply&Infection Wells: In addition to sending the form to+
( rr the address(es) above, also submit one copy of this fort within 30 days of
.(
13b.Disinfection type: Amount: b O Z completion of'well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016