GW1-2022-10790_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: l
1.Well Contractor ori,
ti n: 14:`WATER ZONES I '
Vno
FROM I TO DESCRIPTION
Well Contractor Namur ft, I ft.
1-� .A ft. ft. I
NC Well Contractor Certification Number _ IS.OUTER CASING.for•inultlkased iveUa OR LINER'ilia licable
J'n S IG.�KC r FROM TO DIAMETER THICKNESS MATERIAL
ft. 6,1Z,57 ld SDR,.1 I
Company Name I6.'INNER'CASRVGOR'TUI3ING4 edthermgrclosed-loo
FROM I TO I DIAMETE
2 Well Construction Permit#: (7�\1 I / ft.
THICKNESS MATERIAL
st all applicable well construction permits(t.e.UIc,County,State,Variance,etc.)
ft
ft. ft. 11L
3.Well Use(check well use):
17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ctpal/Pbblic ft. ft.
Geothermal(Heating/Cooling Supply) Wqpidential Water Supply(single) h, g, to
Industrial/Commercial JoResidential Water Supply(shared) 18.a RQUT
IIrI odor FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U fL e, ft. 6eirp ni fie
Monitoring ORecovery ft. ft.
Injection Well: % ft.
Aquifer Recharge ®Groundwater Remediation• 10.SANDIGRAVEL PACK:Ito licable
Aquifer Storage and Recovery'. .a Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ,'•, [3Stormwater Drainage ft. ft.
'a�'�!
Experimental Technology � 1 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.'DRiLLING LOG.attaeb addititinalsheetsifnetessa
FROM TO DESCRIPTION color hardness soWrock size etc
Geothermal(Heating/Cooling Return) ��.O77t--h--e--r(explain under#21 Remarks r�rb ,
4.Date Well(s)Completed: o`O�Y►ell]lD# I tt' D 5tt'
ft. ft.
5a.Well Location:
ft. ft. I
ir 4 ki Q MG&ce Fes:
Facility/OwneLkame
Facility IDN ifa p licable)
ft.
t g� nD/ D0
ft. &
Physical Address,City,and Zip
P ^
al 2I.RE ARKS
OruUG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one tatllong is sufficient) 22.Certification:
pzd 4
Signature of Certified Wefi Contractor
Date
6.Is(are)the well(s) Permanent or E3Temporary
By signing this form,1 hereby certio that the well(s)tvas(were)constructed to accordance
7.Is this a repair to an existing well: ®Yes or %No with 15A NCAC 02C.0100 or 15A 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 ojthi;record has been provided to the ivell owner.
'rdpair under 921 remark;section or on the back of this form. 23.Site diagram or additional well details:
You may use.the back of this page to provide additional well site details or well
8.For Geogrobe/DPT or Closedcloop Geothermal Wells having the same
construction details. You may also'attach additional pages if necessary,
construction,only I GW-1 is needed.'Indicaw TOTAL NUMBER of wells
drilled: = SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: Sd (ft-) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths Ijdlfferent(empple-3 a@2000"hand 2Q100� construction to the following.
10.Static water level below top of casing:`% G d (ft) Division of Water Resources,Information Processing Unit,
Ijwater level Is above casing,use„+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of ttiis'form within 30 days of completion of well
12:Well wnstruction method: �`O��r�� construction to tha following:
(i.e.auger,rotary,cable,'d'uect push,etc.) �—
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!e Iter,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
t the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction tb the county health department of the county
where constructed. ,
Revised 2-22-2016