GW1-2022-10613_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GE-1) For Internal Use Only:
1.Well Contractor Information:
0 ex t' 1 14.WATER ZONES, n -
FROM TO I DESCRIPTION
Well Contractor Name v, -?
�-
NC Well Contractor Certification Number 15.OUTER CASING fte multi-cased:wens OR LINER(if up licabI
in�l! '
FROM TO DIAMETER THICKNESS MATERIAL
� �� 1 Z.G�( 4 (/��,_ ft. �0 ft. H i in. -C. Lf,
Company Name 16.INNER CASINGOR TUBING eothermaldosed-loo).
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. th-
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public G ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft• in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AM UNT lj
Non-Water Supply Well: ft. 44
ft. [ !t D
`_Monitoring DRecovery ft. f I )AC-
Injection Well: \
Aquifer Recharge Groundwater Remediation 't` aa�t
19.SAND/GRAVEL PACK if a 7Vcable'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets ifn&essa.y),-:,_
11 Geothermal(Heatin Cooling Return)
TO DESCRIPTION(color,hardness,soNrmkn etc.)
) Other(explain under#21 Remarks) ft• ft.
4.Date Well(s)Completed: 1�— ? -Well ID# A10 ft. 19 ft-
Sa.Well Location: ft*
ft*
N
'n/ f ' ! ft. ft.
,f`le,/Sf Opr>.r i9iM6,_, a5-_wil rt d .__e
Facility/Owner Name Facility ID#(if applicable)
10LIN rd- doLAjlr- , ,o-,� 1', NOV 2
Physical Address,City,and Zip
31:REMARKS-
�fo�C3t'1 i /F
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,(if welllfield,one lat/long is sufficient) u i1�7 n / u 22.Ce cati n: 1 �_
' I �6��/� .�J�-- 1�fN 7- /9 /g1 /• 0 5/ �7 r/ W G ,;D2-�I— /0-(�Z—%z�9
6.Is(are)the well(s) rmanent or Temporary Sign of Certified Well Co for 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 D?(o with I5A NCAC 02C.0100 or I5A NCAC 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#2I 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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: , SUBMITTAL INSTRUCTIONS
/7 9.Total well depth below land surface: CID (ft-) 24a•For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following: j
i
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.161.7
11.Borehole diameter. a
/ (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: elre? 1 A construction to the following- ,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:e)JOL JY+ 2 24c-For Water Sunniv&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: Ll Amount: ML&i1/ rP completion of well construction;to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmcutal Quality-Division of Water Resources Revised 2-22-2016