GW1-2022-10284_Well Construction - GW1_20221114

WELL CONSTRUCTION RECO _ GW-1 For Internal Use Only:
I.Well Contractor-Information:
Lt e h(I-1 A C AtJ •14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
5.3s 100 f av 0fL
ft fL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER Of applicable)
FROM TO DIAMETER TffiCKNESS MATERIAL
�m• -
Company Name ft ft in
^J 7 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: v1 ��� 77 FROM TO DIAMETER TffiCIWFSS MATERIAL
List all applicable well construction permits(t.e G CormO;State,Variance,eta) 4 t ft. •75' fl S� ;n �T�_ T h �—
3.Well Use(check well use): ft. & im I �t
E3Geothermal
upply Well: 7.SCREEN
ltural r
ROM TO DIAMETER SLOT SIZE TSICIINESS MATERW
❑Municipal/Public m ft. in
(Heating/Cooling Supply) idential Water Supply(single) ft ft. m
ial/Commercial Residential'Water Supply(shared) 1-GROUT
ion ❑Wells>100,000 GPD FROM TO I MATRJUAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. Z ftr
❑Monitoring ❑Recove
Injection Well: ry fe f l
❑A r,rFRech fc ft
AA ,=anIYx
fA
q �e ❑GroundwaterRemediation
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK Of a liable
❑Aquifer Test ❑StormwaterDrainage
❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETROD
ft ft
❑Experimental Technology ❑Subsidence Control ft ft..
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other lain under#21 Remarks) FROM To DFSCREMON color,hanlaesssoiltracktrpe,gmin eta
ft. fL
4.Date Well(s)Completed: Well M0 ft ff
Sa.Well Location: I fL tr
L�Ghhn /Vi(/�,f'DrN & ft,
Facility/Owner ame Facility ID#(if applicable) R ft. S
N•Ck r-qhtti M ctria 4 , —�8 eh '-fL ft: o
Physical Address,City,and Zip fL ft. DNQ Ur*
t � 21.REMARKSI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification•
.33 5 I N $D' �5s• J!!? • W �-
6.Is(are)the well(s): W—ermanent or ❑Temporary 5�i Signature of rWecTfofi Contractor ( Date
_� By signing thisfarm,I hereby cerrIIfythat the well(s)was(wen)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4190 ISA NCAC 01C:0100 or'ISA NCAC 02C.0100 Wed Construction Standardr and that a copy
If this is a repair,fill out!mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple we&list all depths ifdoemnt(example-3Q200'and 2@100) (f t.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ � (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing ive"+~ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
t 24b.For Iniection Wells:Co to D
11.Borehole diameter: fin•) Copy WR,Underground Injection Control(IUC)
1�,� qq Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �7 eLh, /a 1l!~
(i.e.auger.rotary,cable,direct push, 24c For Water Supply and Open-Loop artment Geothermal Return Wells:Copy to the
etc.) county environmental health dep of the county whew installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells nroducine over 100 000 GPD Co to D
13a.Yield m Permit Program,1611 MSC,Raleigh,NC 27699-1611 PY 'CCPCUA
�P ) Method of test t,
13b.Disinfection type: Amount: 0 h.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6 6-2018