GW1-2022-01182_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
t 1.Well Contractor Information: f ` `
FROM
VCIIIyOn ER ZONES
FROM TO DESCRIPTTON
Well Contractor Name ft. ft.
CKW C 4383 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells OR LINER fff avolicable
FROM TO DIAMETER THICKNESS MATERIAL
�, nN ,.�E�S Zi ht�1QC Mn it ft yc"
Company Name J t
16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, rn
17.SCREEN
Water Supply Well: FROM I To I DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
4
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL nIPLACEMENT METHOD&AMOUNT
t
Non-Water Supply WeII: U ft. ft.
Monitoring DRecovery ft. fL
Injection Well: fL ft.
Aquifer Recharge [3Groundwater Remediation 19.SAND/GRAVEL PACK(9 a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT 3IETHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. "L
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESC ION{color,hardness,setUrock e, nun stze,etc.}
Geothermal(Heating/Coolin``g��Return) Other(explain under#21 Remarks) ft. ft_
4.Date Well(s)Completed:"1
[[ ''b®oryry t Well ID# ft , 1 ft. SIA
1 ft. (30,16ft. CTfQn�
5a.Well Location: �^aY v
ft ft.
ft.
FacilkL04crName Facility ID#(if applicable)
ft.
Physical Address,City,and Zip
21.REiVIAItKS
County Gl' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwcu field,one la•Jlong is sufficient) 2.Certification:
N
6.Is(are)the weIl(s) Permanent or Temporary
gnaturc of Certified Well Contractor Date
lll��� signing this jornt,I hereby ceuYify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No th 15A NCAC 02C.0100 or ISA NCAC 02C MOO Well Construction Standards and that a
Ijthis is a repair,fill out kr:owa well construction information n explain the nature oft copy of this record has been provided to the well Quires.
repair under n21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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: OtW (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
I�
For multiple wells list all depths iif'different(example-3@200'and 2@100) construction to the following:
1
10.Static water level below top of casing: CJy (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
-7 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:�.fz-1 3 UTI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
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: �1�Z 24c.For Water SnIIVly&Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type:l'1t71 tC.w Amount:M completion of well construction to the county health department of the county
where constructed.
_r,-____.._...e_.-i n„si;r.,-n;,,;s;—of Water Resources Revised 2-22 2016