GW1-2022-01548_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
I.Well Contra for Information:�j
t" �� 14.WATER ZONES
- F1tOD{ TO DESCRIPTION
Well C ntractor Name ^ {t, .7 it. -
G ft. / G.
NC Well Contractor Cert//ification Number .0 ER ASING for multi-case ells OR L R II a livable
FROM To DIAA TfI1C1CNE/ssss MATERIAL
alpZli (b 7 j ft. -7 1°
Comp ny Name 16,INNER CASING OR TUBIlVG eotherma]closed-100
2.Well Construction Permit#: / �f � �uCl�S � EOM TO DIAMETER THICKNESS MATERIAL in.
List all applicable well construction permits(i.e.UIC,Counly,State,Variance,etc.)
ft. fL
ft. ft iIL
3.Well Use(check well use):
17.SCREEN
rClAgricultural
ater Supply Well: FR011f TO DIAMETER SLOT 512E Tx,c//ICNEss MATERIAL
❑Municipal/Public l°',,�fL � It ZGeothermal Well
Supply) Residential Water Supply(Single) ft ft in
❑Industrial/Commercial /❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM To FATERIAL EMPLACEMENT nt on&AMOUIYI
ft. fL
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. fL
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
L> n /
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neces
FROM TO DESCRIM.. cobs,Ludness,soiVrock e, 'n size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL
4.Date Well(s)Completed:
4L_7jL Well ID# ft ft.
ft. —ft. 7
5a��ep Locatyon: ft. rr
ft. f4
Facility/Owner Name f Facility ID#(if applisabtc _
0 e i's l) t rc rr
1 ft, f4
Physical A4ddress,City and Zip
� 21.REMiARKS
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 ertifica' n• /
I ure of Certified I Contractor ate
6.Is(are)the well(s): [ ermanent or ❑Temporary
/ 8y signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well ❑Yes orj�10 (/ 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jil!out!mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of lhisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For cti on,o only
I G or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / D t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� K (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2 1003
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"+"
L //� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (ln) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /�1 till /�t%1 �p G� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD:Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) r /� Method of test: