GW1-2022-10112_Well Construction - GW1_20221110

WELL CONSTRUCTION RECO (GW_l) For Internal Use Only:
1.Well Contractor-Wormation:
6-e Ci 0/LJ 14.WATER ZONES A
Well Contractor Name FROM TO DESCREMON
3535 oaft' SZv&
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased welts OR LINER if applicable)
FROM TO ft DIAMETER in. THICKNESS MATERIAL
Compaq Name
. ft
7 16.INNER CASING OR TUBING eothermal cloyed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.&W,County,State,Var/anee,etc.) �. it. R }t 7181. in.
i PLt.
3.Well Use(check well use): ft. ft -in.
Water Supply Well: dJ7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft
❑Geothermal(Heating/Cooling Supply) f esidential Water Supply(single) ft .
❑Industrial/Commercial ' Residential Water Supply(shared) 18.GROUT
❑Irri tion ❑Welts>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z3 ft,
❑Monitoring ❑Recovery g, tt
Injection Well:
❑A uiferRechar a R' ft
9 g ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19•SAND/GRAVEL PACK f a licabla
FROM I MATERIAL ERT1ACEMENTMETHOn
❑Aquifer Test ❑StormwaterDrainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. it
❑'Geothermal(Closed Loop) ❑Tracer 10.DRII LING LOG attach additional sheets if necessary)
❑Geothermal eating/Cooling Return ❑Other(e lain under#21 Remarks PROM TO DESCRIPTION color hardness sot/,n.b in a' etc
ft ft
4.Date Well(s)Completed: I -Z •2L Well ID# ft ft.
55a.Well Location: ft• ft. e ;
7-A rl K ft. NOV I
Facility/Owner Facility/Ownerility/Owne Name 1? Facility IDN(if applicable) - � B• h
Ti he J t� — fa S A � � 1' ,tt. ft•
Physical Address,City,and Ap Tft� ft
_ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lonng N Dis sufficient) pp 22 Certification:
36 -2 41 � f s � � � W
6.b(are)the well(s): ermanent or ❑Terora 1 Signature oflerti6ed'� ell Contractor
p rr 3 b 20 Date ,
Bysigning this form,I hereby certo that the well(s)was(were)constructed in accordance with
�,`•
7.Is this a repair to an.existing well: ❑Yes or 0 15ANCAC 02C:0100 0r'75A NCAC 02C.0100 Well Construction Standards and that a copy
If th/s/s a repair,fill out known well construction information mid fain the nature of the of this record has beenprovided to the well owner.
repair under 021 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 construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
-1 r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S u (ft,) i
For multiple wells list all depths jddereiit(example-3(a)100'and 1©100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below fop of casing: (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
{(water level is above casing,use••+ hmfotmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: , 3 (in) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Welt construction method: fy��t,,_ �• Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push etc.) s 24c.For Water Su 1 and O'en-Lou Geothermal Return Welts:Copy to the
county environmental health eptuhnent of the county where inst led
FOR WATER SUPPLY WELLS ONLY:
.24d.For Water Wells Droducini over 100 000 GPD•CoPpto DWR,CCPCUA
13a.Yield(gpm) Method of test Permit Program,1611 MSC,R�leigh,NC 27699-1611
ll r tt
13L Disinfection type: T 70 Amount:_►� '
y
Form OW-1 North Carolina Department ofEnvimnmentat n„aliw rur­n___1___