GW1-2022-00865_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
I
]Jr ��y1 G rZT 2 6� 14.WATER ZONES
Well Contractor Namc FROM TO DESCRIPTION
Tt. �
2 q 53z. .
ft. ft.
NC Well Contractor Certification Number
[�r 15.OUTER CASING for.multi-eased wells OR-LINER if a licable
O V P,4- �( ��� I L�1 0 6— FROM ft. TO ft. DIAMETER THICKNESS MATERIAL
n,
Company Name
q 16ANNER CASING OR TUQING eothermal'dosed=loo
2.Well Construction Permit#: .J fy j/ © FROM TO DIAMETER THICKNESS MATERIAL
Lid all applicable trell constiucrion permits(i.e. U/C,Counh'.State, Variance.etc.) ft- - �� {L q. in. 56j/) p v�
3.Well Use(check well use): ft. ft. in. f/
Water Supply Well: 17.SCREEN
FROM TO DIAMETER =EMPLACEMENT
L
Agricultural Municipal/Public ft. Al' iti•
Geothermal(Heating/Cooling Supply) QlRcsidential Water Supply(single)
Industrial/Commercial QRcsidential Water Supply(shared) 1s,GROUT
Irrigation FROM TO MATERIALNT
8Monitoring
on-Water Supply Well: ft. c7
Q,Rccove n.
rY ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery QlSalinity Barrier 19.SAND/GRAVEL PACK(if alicable)
FROM TO MATERIAL rMPLACEMENT nteTHOD
Aquifer Test QlStonnwater Drainage ft. ft.
Experimental Technology QlSubsidence,Control
Geothermal(Closed Loop) QTracer 20.'DRILLING LOG(attach adtlitiohal sheets if n&iassar d
Geothen-nal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hnnlness,soiUrnck t e,grain'sirG etc.
1 C ft. 1•
4.Date Well(s)Completed: j0.� �� Well ID# t• 0 ft. �Lh t�e• G G
5a.Well Location: ft. ft,
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M/+Rv A -7'lA-A-hwi`
Facility/Owner Name Facility ID#(it'applicable) ft.
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` o�ll�I� JA
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: -`
.y
N 1 G d r7` `3, = Cl 7 w `/t� fZ,� r
6.Is(are)the well(s) Permanent or QlTemporary S' ofCcrtificd Well Contractor Date
// ,, By signing this fiwin, 1 hereby ce"101 tear the well(:)was(ivere)consinteted in accordance
7.Is this a repair to an existing well.. Yes or QNo with 15A ArCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard,•and that a
lfthi.s is a repair,ill out known ivell c'ons[rne'[i nfitnnation and explain the nature a'the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the hue of this fin tn.
23:Site diagram or additional well details:
3.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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: enNlf<� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � ft,)" ( 24a. For All Wells: Submit this form within 30 da s of com letion of well
For multiple wells list all depths ifdierent(example-3(,,200'and 2@100') construction to the following: y p
10.Static water level below top of casing: (ftJ Division of Water Resources,information Processing Unit,
IJ water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Ii (in.) 24b. For infection Wells: in addition to sending the form to the address in 24a
7 2�
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
�`�� ��
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l
13a.Yield(gpm) _ Method of test: 24c. For Water Supply & lnjection 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: 1� ;U Amount: Zi. completion of well construction to[the county health department of the county
where constructed.
Form GW-I North Carolina Department of Envinwmenial Quality.Division of Water Resources