GW1-2022-00279_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
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1.Well Contractor Informaation: —
JO�lNn 16(rjr_FI 14.WATER ZONES - ._-
-
Well Contractor Name FROM TO DESCRIPTION
"7 r 0 �i�ft. ft. Gr pi'rl
ft. ft.
NC Well Contractor Certification Number- IS.OUTER CASING(for multi-sised wells)'OR LINER(if ap licable) .
IA31 �3 FROM TO jO DIAMETER THICKNESS MATERIAL
�- 111� C�� Jam'� Z/ ft. _/D f t. �pP'.7 in. C 'z, put.,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): - it. ft. In.
17.SCREEN
Water Supply Well: .. ` .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural fD. M cipal/Public 0 it• ft. in.
Geothermal(Heating/Cooling Supply) 2kesidential Water Supply(single) R. R, in.
Industrial/Commercial OResidential Water Supply(shared) `18.GROUT -
Irrigation FROM TO MATERIAL j EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: to ft. 146 f t. 345 r'1-t/O/e p 14:5 fec'''' '0441/1
c
Monitoring . Recovery ft. ft. ��
Injection Well: �� .:1-. P
ft. ft. q s.
Aquifer Recharge Groundwater Remediation � l A
cos
19.SAND/GRAVEL PACK(if applicable)':
Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft. ,:,.2'.
I :Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,eta.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
6 ft. ft. (9v,csb.;�-de
4.Date Well(s)Completed: /1"3`2O22_Well ID# •� ft. _� ft. 41 e_hzi -
Sn.Well Location: ,�1� ft. ! ft. ,2_ e—i.4/ CD_ D f
1 e,(.0 . c)01- f--`r,en G5 ft. e7 ft. �+
Facility/Owner Name. Facility ID#S (if applicable)) ft.
ft. ft.
ci1A—io� ��'/`,(ion 4), O c4 0 !�e- ft. ft. z '. ,,_.,.;ram_.",.'! Fr;'+a
Physical Address,City,and Zip -757'S' ft. It. i 5.1:m..\,..c'Ib....6 V IL,LI
Gt":6-e YN.4, ilie- '�0lJ00c7 J07 21.1t
EMARKS .r. Jrr if rt LULL
County Parcel Identification No.(PIN)
r
lrtiiNi bn ,O rim... wg U WI
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: Etf,:Or;;;,u
' (if well field,one lat/long is sufficient) 22.Certification: '/
3(p. Z /qf 7 N '78., (' CM /� W �Q 1/ - -2�,7
6.Is(are)the well(s) rmanent, or Temporary a of Certified Wel on c Date
�i 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: DYes or DK, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: 1
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: &(9 n (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(t200'and 2@100') construction to the following:
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 27699-1617
11.Borehole diameter: 6'1' (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 welt.
p���
12.Well construction method: XEi %'j. 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
.2
r/ �y
13a.Yield(gpm) X 64 .-i Method of test: �o i'i c9,,, c.For Water Supply'&Infection Wells: In addition to sending the form to
^y the address(es) above, also submit'one copy of this form within 30'days of
13b.Disinfection type: 11 T/'f Amount: 2-7 ()..,z,e r5 completion of well construction to them county-health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources { Revised 2-22-2016
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