GW1-2022-00273_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.V,ell Contractor Information.
f�G r � O/��,��— 1'4 WATER ZONES l I
V FROM TO DESCRIPTION
Well Contractor Name �— ft. ft.
�15�15-A
NC Well Contactor Certification Number 40yMnASING'.#or•in eased wells OIt1,INER i[.aTO DIAMETER THI S MATERIAI
tit.J
Company N a 1�fr SICVG OR'TlJ$ING edthermal'crosad+loo2.WellConstrucdonPermlt#: //, &Dt`1ITJ>1 TO IAR TList all applicable well construction permits(i.e.UIC,County,Stare,4arlance,ere.J ft.3.Well Use(check well use):Water Supply Well: O DIAMETERIYESS MATERIAL
Agricultural ,0MunicipaV tblic r•
Geothermal(Heating/Cooling Supply) aRgsidential Water Supply(single) ft. to
IndustriaUCommercial Residential Water Supply(shared) 1s,dItQUT
FROM TO -EMPLACEMENT METHOD&AMOUNT
1rri ation fL ft. L' 1-1
_ Non-Water.S_upply Well:
Monitoring r3Recovery ft. -ft.
Injection Well: ft. ft.
.Aquifer Recharge Groundwater Remediation 14.SAND.t 9AVEL PA. --.I(a licalile
Aquifer Storage and Recovery C)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage fL tL
Aquifer Test ;a`�.,;
Experimental Technology - :r [)Subsidence Control it, ft
Geothermal(Closed Loop) OTmcer 20,'DRILLIN OG. ttaeb d IHbnglsheet:lfnecessa
FROM TO DESCRIPTION color hardnese solUrock size eta
RGeothermal(HeatinglCooling Return ..Other(explain under#21 Remarks 6-ft. G B, I . 1
4.Date Well(s)Completed;) Z Well ID# �� ft: �J5 ft. i
% ft. {,
Sa.Well Location:
A.
it CtCs�� lycli St l "
,ot ft. ft. 1 a nz., .,..•+ ..b E.yt•
Facility/Owner Name Facility ID#(ifapplicable)
ft. 2 2 2022
ft. ft. i!
Ph sicaI Address,City an ip
,,zz ZI.RE ARKS l tfliti�:y Fciv. +-Pxu
(-7aS{-�vt
County Parcel identification No.(FIN)
5b.Latitude and longitude In degrees/minutes/secon4s or decimal degrees:
(if woo field,one latllong Is sufficient) 22.Certification: "
35,3755 i�t N = 12 IGR W = :: �'= -- -,. j�- [ 3 '•�2
kV Signature ofCartiHed ell Contractor Data
6.Is(are)the well(s)oPermanent .or Temporary.
By signing this form I hereby certify that the wells)was 6vere)constructed in accordance
7.is this a repair to an existing well: E)Yes or MNo with!SA NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a
Ijthcr Is a repair,Jill out/mown well construction information and explain the nature of the copy ojrhis record has been provided!o the well owner.
rdpalr under#21 remarks section or on the back ofthts form. 23.Site diagram or additional well details:
Is or well
8.For Geogrobe/D I oPT or Closed- o•P 6tbcrmal Wells having the same You may use the back of this page to provide additional well site detaiconstruction details. You may also attach additional pages if necessary,
construction,only 1 GW-1 is needed.•Indicate TOTAL NUMBER of wells
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 U�5 (ft-) 24a. For All Wells: Submit tills form within 30 days of completion of well
For multiple wells list all depths(fd�erent(example-3(�00"and 2Q1001 construction to the following•
` Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:?` to G (ft.) 1617 Mail Service Center,Raleigh,-NC 27699-1617
Ijwater level is above easing,use"+' 11
11.Borehole diameter: �_ (In.) 24b.For Infection 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. r /o construction to the following: i,
(i.e.auger,rotary,cable,direct push,etc..) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Serviceitic
Center,Raleigh,NC 27699-1636
Method of test: �`r- 24c.For Water Suanly&Inie n Wells: In addition to sending the form to
13a.Yield(gpm)- the address(es) above, also subunit one copy of this form within 30 days of
'r 1 N Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
North Carellne Department ofBnviroomental Quality-Division of Water Resources
perm OW-1
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