GW1-2022-00300_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
A.WATER ZONES
FROM TO
1 + . DESCRIPTION
Well Well Contractor Name O tn
io&2-
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER if a livable)
' ;� T C n'/� FROM TO DIAMETER I THICKNESS MATTE�RIIAL
W RTE RZ t J.T Z&Q -r O
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in•
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i Municipal/Public p ft. ft. in.
IIlGeothermal(Heating/Cooling Supply) I Residential Water Supply(single) ft. ft. in.-
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 49 3 14OL6. pw 'S 01 b 5 Pomeh
Monitoring EIRccovery
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EStormwater Drainage
Experimental Technology oSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,son/mck type,grain sim,etc.)
RGeothermal Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: I2 1�-2� Well D# 953 7
ft. ft.
5a.Well Location:
14F12mlco 1 I COSG
Facility/Ow'neerr Name
� Facility IDD#(if applicable)
L ft. ft.
Physical Address,City,and Zip ft. ft. P i::•`s•=%v3 l!r;S
: Lo-�J 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 1
3&-;Z611 g63(0 N -78. 1931 1 w
6.Is(are)the well(s)MPermanent or OTemporary ature of Of tied Well Contractor Date
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: E]Yes or DNo 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 Wells 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: / DQ 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 a200'and 2@100) construction to the following:
II
10.Static water level below top of casing: a5) (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C i nter,Raleigh,NC 27699-1617
11.Borehole diameter: b (in.) 24b.For Iniection 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: Or�'` 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;C(enter,Raleigh,NC 27699-1636
13a.Yield(gpm) toMethod of test I+o-oN 24c.For Water SnaDIv&Iniection Wells: In addition to sending the form to
� Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: NT �-I1 Amount: O 0 Z- completion of well construction i to,the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016