GW1-2022-00202_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1_Welt Contractor Information:
tllill\. G1 p116 1�'✓) 14.WATER ZONES
Well Contra torName FROM TO DESCRIPTION
�/ ft. O ft ,0, &�
's Sa ft. �0 ft. I'V; ��••'��t VV-%
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER if ap licable)
lisle 's �`�� �r Il i 1 n c • FROM TO DIAMETER THICKNESS AI ERIAL
ft rL i v C�
Company Nam
f.
16. R CASING OR TUBING geothermal closed400
2.Well Construction Permit FROM To I DIAMETER THICKri'ESS. 31ATERLIL
List all applicable well construction permits(i_e_VIC.County,State,Variance.etc.) n• ft• in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO i I DLkMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaVPublic ft. I ft. I in.
❑Geothermal(11cating/Cuoling Supply) 19Residential Water Supply(single) ft. I ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑hTigation ❑Wells>100.000 GPD FROM I TO MATERIA E:\IPLACE,\IENNT METHOD g AMOU.NT
Non Water Supply Well: fL z ft � 1
❑Monitoring ❑Recovery ft �✓ O Rt �y
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. E\tPLACE.\=AIMIOD
❑Aquifer Test ❑StotmwaterDrainage R. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(HeatingfCooling Return) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION(cot .hardness•sofffracktype.grain size,etc.)
rr. g n f_ S�I
4.Date Well(s)Completed: ll ID# I h•
5a.Well Location:
ft. . ft.
Facility/Owner Name FacilitylD#(ifapplicable) IL r 5 i
q S D U jwl e Ck �J L �,���u'7 ft. ft. fv. V 4
Physical Address,City,and-4 - rL B�
4 1r I .U.Lr - DEC 1�
az1.REMARKS
County a. Parcel Identification No.(P1N) Ir1ii�F�:.3;'� ^?�^• ;3 IJT;i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer [cation
3b. _�)l RLt`f N rl�s �5 to� W} .J - R02
6.Is(are)the well(s): Permanent or ❑Temporary Sigaat ofC rtified Well ntractor Date
�,�T 1h,signing this form,I hereby certifj'that the uvil(s)was(mere)constructed in accordance x ith
7.Is this a repair to an existing well: []Yes or KNo 15A AVAC 02C-0100 or I5A NCAC 02C.0100 Ffrell Construction Standards and that a copy
(this is a repair,fill out btoim mall construction information and explain the nature ofdue ofthis record has been provided to the ivell owner.
repair under#21 renuarb section or on the hack oJ'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 I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(i 200'and 2@100�
10.Static water level below top of casing: .�C (ft) 24a. For All Wells: Original-form to Division of Water Resources (DWR),
If water level is above casinZ use"+"
Information Processing Unit,160 MSC,Raleigh,NC 27699-1617
11.Borehole diameter' (in,) 24b.-For-Injection Wells:Copy to DWR,Underground injection Control(TUC) .
Program, 1636 MSC,_Raleigh,NC-27699-1636
12.Well construction method: Il 0 /
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) - _ county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,-1611 MSC,Raleigh',NC 27699-1 6 1 1
13a.Yield(gpm) I. o d� Meth of test:�__ _....__
13b.Disinfection type:►l 0 CY/llQ Amount: t 5 �Z
i
Form GWA North Carolina Department of Environmental Quality-Division of WaterResouaces Revised 6-6-2018