GW1-2022-00298_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
o
��� 1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft.
30 P� �} ft. I
ft.
NC Well Contractor Certification`Number '15.OUTER CASING for multi
1 1 1 -eased wells)OR LINDER Iif a livable
ge Vv 1-7 7�V J �.F!v V{ FROM TO It- r DIAMETER in. �/�•(�� MArile,
Company Name 116.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit# FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER - SLOT SIZE THICKNESS MATERIAL
—)Agricultural M icipal/Public ft. ft. in.:,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft• ft• in.I
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1tri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft ft f10L8 QI,u
Monitoring Recovery
Injection Well:
! Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if a licablc
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test DStormwater Drainage
1 Experimental Technology DSubsidence Control
r Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfmck rain size,etc.)
? ft. ft. ✓G r
4.Date Well(s)Completed: V �CKOVellID# AfV,'l) 23& ft. ft.
ft.
5a.Well Location: ft.
T-&m►gs 1:6RRELL
Facility/Owner Name �{ Facility ID#(if applicable) ft. ft. ;.;y jl,�R,i at ! a
V t
Physical tAddress,City,and Zip L ,
21.REMARKS
1DtLI P�'.r✓il "'"�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lat/long is sufficient) 22.Certification:
�t y�177? 4o N _W
6.Is(are)the well(s) f_ Permanent or Temporary Si afore of Certified Wel ntrector Date
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo 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 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page 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 if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10 D O (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: OZ 5+C
(ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n OTA� �r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: !� �I` 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
13a.Yield(gpm) I Method of test: U 24c.For Water Supply&Iniection 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: !4T 1 14 Amount: O Z completion of well construction to Ithe county health department of the county
where constructed. i
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016