GW1-2022-00294_Well Construction - GW1_20221222

1 I111\1 VI1,1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor
r Information:
G.f L Cook-
ook- 14.WA IBR ZONES
Well Contractor Name FROM! TO OFSCRI'TION
y$7� AGPM
NC Well
1Contrractor'Certification Number ra.OV7ER CASING mumtasea Fit' A rave
WaTU W;Zards 'Zoe- FROM TO DIAMaIER TR/CKE MATERIAL
Company Name 0 ft. to 3 ft. I to 1 In. ISD 1Z a' ✓C
16.INNER CASING OR TUBING closed-too
2.Well Construction Permit#: 4da -0 12 FROM To ouMRrart TIMMIES5 MATERIAL
List all applicable well construction Permits(ice.UIC,County.State.Variance,etc.) ft. I. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
mom I To I OtAA1S1'SR I swTstta Tlffl -cs I MATERIAL
Agricultural E)Mmicipal/Public D fL 2 to
Geothermal(Heating/Cooiing Supply) residential Water Supply(single) ft g in.
Industrial/Commercial DResidentiai Water Supply(shared) Ice GROUT
Irrigation mom To MATERIAL I EMPLACMUNTWITHOoa AMOUNT'
Non-Water Supply Well: ft' ft.
Monitoring DRcmvcry
Injection Well:
_ Aquifer'Recharge Groundwater Remediation ft
19.SANDIGRAVEL PACK fifa Able
Aquifer Storage and Recovery ®Salinity Barrier PROM TO NUTIE MAIL EMPLACRMENT METIOD
Aquifer Test [3Stomlwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG attach additional sheets A necessary)
Geothermal Heatin Conlin Return) rJOther Cmplain under#21 Remarks) FROM To DESCRIPTION(color,hudnm,sciVmde in acc,ae.
�1 0 ft. 5 n'
4.Date Well(s)Completed: II-9-2c2 WeUM# Ua 3aI'0 & 5
ft. 0 ft. j clay
5a.Well Location: g C) ft oo rc. fr J R c
ft. ft. �
Car-L450 NOMGS
Facility/Owner Name Facility ID#(Uapplicable) ft. ft.
ie
al a w Eye, len t un� A01 s6000U66 Nc_,�z ft. ft
es a1W — a
physical Address,City,and 73 ft. ft. .I...... fr_^ram_ T19
O rwn wP- 99'653(6_2A.
County Paroel Identification No.CPIN)
5b.Latitude and longitude in degrees/minuies/seconds or decimal degrees:
(ifwell field,one lafllong is sufficient) 22.Certification:
N W ! (/� H S77A II 9 a2a
6.Is(are)the well(s)ErPermranent or Temporary Siguatwe of Certified Well Contractor Date
4 signing this form,I hereby cerror that the well(s)was(were)conuructed in accordance
7.Is this a repair to an existing well: ©Yes or E�No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthb is a repair,flit out known well construction information dad explain the nature of the copy of this record has been provided to the well owner.
repair water#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Gwpmbe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this puge to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUC3TON3.
9.Total well depth below[and surface: 3 00 (ft.) ylo, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dtJ/event texmnple-3Va 200'and 2@I aO) construction to the following:
10.Static water level below top of easing: lag (ft.) Division of Water Resources,Information Processing Unit,
If hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (0 Vir (in.) 24b.For Iniecion Wells: In addition to sending the form to the address in 24a
f� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 W in.r4 construction to the following:
(i.e.auger,rotary,cable,direct puab.atc.)
Division of Water Resources,Underground Injectioa Control Program,
FOR WATER SUPPLY WENS ONLY: 1636 Mail Service:Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 50 Method of test: B Ion A o20 pj8 24c-For Water Supply&Inaction 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: 11C.(4 Amount: 13 O Z completion of well construction to the county health department of the worry
where constructed.
Form GW-1 North Carolina Department ofEnvirommmml Quality-Division of Water Resources Revised 2-22-2016