GW1-2022-00989_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only:I.Well Contractor Information: /
0d"( 14.•WATER•ZONBS
Well Contractor Name FROM "I'O DESCRIPTION
c s - 5
NC Well Contractor Certification Number ft• ft.
® n fl 15:OUTER CASING`(for.multi-cased wells OR LINER.if a-' licable
r, h �(L� 9 A) eI FROM TO DIAMETER THICKNESS MATERIAL
Company Name / ft. ft• in
2.Well Construction Permit#• I6i INNER CASINGORTUBING" eothermal closed-loo
d FROM TO DIAMETER THICKNESS MATERIAL
1_isl all applicable well construction permits(i.e. UIC.Cotalp•.Stale, Variance,etc.) , ft, ft. in.
3.Well Use(check well use): ft ft in
Water Supply Well: -17;SCREEN
Agricultural D.
Municipal/Public FROM M
TO DIAMETER SLOT SIZE THICKNESS MATERLAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) csidential Water Supply(single)
Industrial/CommercialM ft• rt• in.
Residential Water Supply(shared)
Im ation 18•GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. /
Ii Monitoring Recovery )67
Injection Well: _. ft• ft.
Aquifer Recharge oGroundwater Remediation ff tt.
Aquifer Storage and Recovery Salinity Barrier 19 SAND/GRAVEL PACK(if a 'Iicable
FROM TO MATERIAL E
;Aquifer Test QlStonnwater Drainage it. I. MPLACEMENT METHOD
Experimental Technology DSubsidence Control
i Geothennal(Closed Loop)
ITracer
20..DRILLING LOG(attaeh necessa
'additional sheets if ry
Geothennal(Heating/Cooling Return) Other(ex lain under#21 Remarks) FROM ru DFSCRIPTION(color, -//,hardness,soillrock type, rain size,etc.)
/ ft. ft. 7'1 CL 4,Date Well(s)Completed: ��yclll ID# ft. 1✓ ft.
5a.Well Location: � tt. s-•^"R.
�Qh ov P 1w-m ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
135�h e ii-� bk ��
Physical Address,Guy,and Zip ft
l ♦",T� t�� t 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:
3y° y3 ' tZ �N
6.is(are)the wells) 44,��
Permanent or Temporary Skg.2.gul'cOtUclllficdWCII.C70ntrdctor i _ 7
Date
CCC By signing this(rmn, l hereby certify that the we(I(s)was(were)construcled in accordance
7.Is this repair to an existing well: Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C'onStruction Standards turd that a
!/•[iris is a repair,jt//out known well construction infornhalion[ explain the nature of the c'op1'of this record has been provided to the we/1 owner.
repair under#21 remarks section or oil the back of this./bon.
23.Site diagram or additional well details:
R.For Geopenbe/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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_Al
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (ft.)
For multiple wells list all depths ijdiereal(erantp/e-3@000'and 2([v100') 24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following;
' Static water level below top of casing:_ (ft.) Division of Water Resources,Information Processing Unit,
/junter 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:_ o-{ ,3,rz / above, also Submit one copy of thiS form within 30 days of con lecion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: p
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Itiection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (i� Method of test: 24c. For Water Supply& Injection Wells: In addition to sending the form to
f Q y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. ® .1 ke— Amount: �t 0 yf completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Denanment of F.nvi rn ntnl cl—i;.._n;..;..;.,