GW1-2022-00972_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
�.Vjn 6A e _, 14.WATER ZONES
Well Contractollblame FROM TO DESCRIPTION
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NC Well Contractoor Certification Number 15.OLr ER CASING for multi eased sdls OR LBVSR der ble
1 t7.X \5 l e-14'S �11 i FROM TO DIAMETER THICKNESS MATERIAL
Company Name nn ® 16.INNER CASING OR TUBING thermal desed-ioo
2.Well Construction Permit FROM TO DIAMETER I THINS MATERIAL
List all applicable well aanstrrtction permits(ere UIC,County,State Yarimuce eta) B• R•
3.Well Use(check well use): It. B• m
SCREEN .
Water supply Well: 17.FROM TO D1AME= SLOT SIZE THICKNESS MATERIAL
Agicultural []MunicipaWalic U n n in.
Geothermal(Heating/Cooling Supply) JaResidential water supply(single) n n m.
IndustriavCommercial Residential water supply(shared)
18.GROUT
_11rrigation FROM TO MATERIAL EMP ACEMENTAIMMOD&AMOUNT
Non-Water supply well: © IL fL UA7'
_. Monitoring OR—very 3 IL p n
Injection Well:
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Aquifer Rechatge Groundwater Remediation 19.SAND/GRAVEL PACK der nhle
Aquifer Storage and Recovery [:]Selinily Barrier FROM I To MATERIAL EMPLACENEE iTMETHOD
Aquifer Test OStormwater Drainage B• R
Experimental Technology []Subsidence Control it, I It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooh g Retum) FlOther(explain under#21 Remad.) FROM TO DESCRD'1TON r,ru�6s,so0tractc sae,etc
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4.Date Well(s)Completed:L Well ID# 1 ��y�5 n n f k .
Sa.Well Location: —B• ,�ft
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Facili Name' Facri1ity IDH(if applicable)
n B. JAN 7
Physical Address,City,and lip n ti'
2L REMARKS
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaillonggiQis sufficient) 22.Certification:
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6.Is(are)the•well(s)CiPermanent or Temporary Srgoaturc of ertificd well o tractor Date
����III1 By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is.this a repair to an esisting.weti: . Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fiu out known well construction Information lain the nature ofthe copy of this reoord has been provided to the welt 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: S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3C3a 2 'and 2@100) Construction to the following:
10.Static.water level below top of easing: Sla (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: (in•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction method: {�} } R1� above, also submit one copy of this form within 30r days of completion of well,
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division.of Water Resources,Underground Injection Control-Program,-
FOR WATER SUPPLY WELLS ONLY: Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1\/` 24c.For Water Supply&Injection 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: Amount: completion of well construction to'the county health department of the county
where tx>nshucted
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resourcils Revised 2-22-2016