GW1-2022-09535_Well Construction - GW1_20221014

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Q41�1 n ?._ nuts le.l 114:WATER-ZONES ..
Well Contractor Name FROM TO DESCRIPTION
.�y ft �� tl. ; �
3 541 f 65-ft�'- /75-'L �' m
NC Well Contractor Certification Number 15:OUTER`CASING formulh-cased wells'OR-LINER'if u``hcable
t FROM TO DIA$�TER THICKNESS MA=IAL --
R-2 sIe4. 0ell �r'%Kt VVA fh� . , . L-
Company Name ' 1 q e I V {
9/ / �1&-INNER CASING OR TI)BING: eotheimal closed4o . - _
2.Well Construction Permit#: Jk6o%S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc.) H• H• in-
3.Well Use(check well use): ft ft. in.
Water Supply Well: 1Z;SCREEN _
FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL
i,Agricultural QMunicipaY%blic U ft ft im! `
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) % H.
__ hidustrial/Commercial Residential Water Supply(shared)
,18.GROUT
Irrigation FROM TO . MATERIAL n1rLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n n- y11f-A LLVA e
Monitoring Recovery _ 3 ft. oZa ft `- -
Injection Well: ape �f
ft. ft
Aquifer Recharge DGroundwaterRemediation
.19..SAND/GRAVEL'PACIC ifa livable
3Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
34quifer Test O Stormwater Drainage R M
Experimental Technology OSubsidence Control R• R-
i ,
Geothermal(Closed Loop) OTracer -20-DRILLING,'LOG attach:addit➢diiA`sheetsifneeessa
Geothermal(Heating/Cooling Return)' _ Other(explain under#21 Remarks) FROM TO .DESCRIPTION color,hardness,soil/rock type,grain size,etc) '
sot. .
4.:Date- ell(s),Completed 0 5-- 3-3- Well I11)9-3t16©1.r� :g: .n rpc�Vt S>'GLl Wle. �0c-tt_
5a.Well Location -.. . .. .-..
ale x
ft
Facility/Owner N e , - -FacilityID#(if applicable)- ,
30 V 1 Fir W, eAI O c Gk : n1 �,5--ti�1 n Physical Address;City,and Zip, i _ t "ft. ft
'21.;REMARK:S
0 _ -
Couity Parcel Identification No.(PIN)
lll7ui ai n"9"1 t'f^s°3r.eOlt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: '
ii
6el6 N. ��s `?�lv--Z SS3 W
to D
-6..Is(are)the well(s)&Permanent or [ITemporary Signature of CAfied�Well Contractor 0 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: OYes or E)No with 15ANCAC 02C.0100 or 15ANCAC 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:
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: _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z S' (D•) 24a. For,A11 Wells: •Submit this'form within 30 days of completion of well
For multiple wells list all depths if di•B"erent(example-3@200'mid 2@100�
++1� rconstmctionrto the following: - - - - •
10.Static water level below top of casing: os (fk) ` ('Division of Water Resodi ces;Infoi matiou Processing Unit,'
Ifwaterlevel'is above casing-use i+ =- , = -. -,.- 1617 Mail.Service C nter,Raleigh,NC17699-1617
11.Borehole diameter: ro (in.) 24b.Foi-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'
r e au rotary,cable,direct push,etc.) 07 R
•. ., 1. ooiistruction to the following: j
12.Well construction me hod - fT Q
(. . ger,ro p
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: 2 i C 24c.For Water Supply&Iniection 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: C, Ort 0— Amount: 00 ®2 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 I Revised 2-22-2016