GW1-2022-01718_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD(GW--1) For internal Use Only:
1.Well Co /ract)or Information:
(` t L �Q /� 14.WATER ZONn
Well Contractor Name d ft 202. IL I q 3�H TO DESCIMMON
gQ 3 --4 ' &0 ft 1Yz it ti P/n
2A0
NC Well Contractor Certification Number
FROM TBRC UM for multi.-cased welts O HI THICKNESS
S t[MAT
(vim l/ I/ly, FROM TO DlAhib"ffit T�CIQVESS MATERIAL
Company Name I M ft I 6' u- I L5VR-2' vG
3{1 7_I� 1 16.11MR CASING OR, UBING(spothermaldesed-loeal
2.Well Construction Permit#.. ✓ FROM TO DIAMETER I TelCKNESs I MATERIAL
Listall applicable tw1levash-actionpardu(Le-UJC Cowu};S?m Vananea eta) ft & in
3.Mica Use(cbeslrwea'use): h• ft in
Water Supply Well: 17 SCREEN
FROM I TO I DIAMETER I SLOT Sim I Tiucm ss MATERIAL
Agricultural aVPublic D• ft in.
Geothermal(Heating/Cooling Supply) ffRcsidentiaiWater Supply(single) tt fL in
industrial/Commercial Residential Water Supply(shared) 11L GROUT
'on FROM TO MATERIAL EMPLACEMENT DUTHOD&AMOUNT
Non-Water Supply Well: & :zo ft Pao r-e
Monitoring DRecovery ft ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salim Barrier `SAND/GRTO 1'.►CK' a IIcable
nY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage R• D•
erimentat Technology 11SubsidenceControl fL ft
Geothermal(Closed Loop) ElTracer 20:DRnjMG1:oG attaeh�additional-sheetsifnecessa
Geothermal(H cling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness•saWraek rain sia etc.)
ft. Zd it r
4.Date Well(s)Completed: I 1'30-Z 1 Well ID# Z I R' 2• U R' 47 P jAn i7 a im C S'}v►
Sa.Well Location: fL ft.
Derr (Tones ft. fL ( =r_ /'Z,r .�.,
_ >,.-
Facili[yl0wucrNamc Facility M#(ifapplimble) tt• R•
( 7200 PVC-?r Cre4on. NC,2 K15 ft. ft. p 9
Physical Address,City,and Zip p �p,.,� ft• ff•
21.REMARKS
County Parcel IdentificationNo.(PIN) ;
5b.Latitude and longitude in degrees/minutee/seconds or decimal degrees:
(if well field,one lattlong is auffrcient) 22.Certifieation:
3G,g27q'f N _�r1.6607 W
6.Is(are)the we11(s)0,S*e1'rmanent or OTemporary Signatm ofCertified tractor Date
By signing this form,I hereby cerf#y that the ue11(s)was(tivem)constructed in accordance
7.Is this a repair to an eidsting well: [3Yes or Y N-11 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repak fUl out known well constrttetlon Infamunlon and explain the nature ofthe copy of this record has been provided to the tvetf owner.
repair under#21 remarks section or on the back ofthis 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 i GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 40 - M) 24a. For Aa Wells: Submit this forth within 30 days of completion of well
For multiple wells h'st all depths ifdifwant(example-3 a@200-and 2@100) p
construction to the following
10.Static water level below top of casing: 20 (ft) Division of Water Resources,Information Processing Unit,
If venter level is above ceasing,use"++^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G I (m.) 24b.For Ittiection Wells: In addition to sending the fonn.to the address in 24a
12.Wea construction method:A I -
above;also submit one copy of this form within 30 days of completion.of well
lie.auger,rotary,cable,d rect p-1%etc.) construction to the foliovtirrg
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ram! Method of test: l 1 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: T Amount: J 6' the adedres of ll constructionovalso th
e county of this
form within
30 days of
department of the county
where constructed.
Form GW-1 North Carolina Department ofEavironmentai Quality-Division of Water Resom= Revised 2-22 2016