GW1-2022-01719_Well Construction - GW1_20220207

WELL CUNSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Con or Information:
(]lam D ��G✓^ 14.WATERZONES
Well Contractor Name FROM TO DESCREMON
q0 a-3 90 e. qZ IL 7s� 9re r rfe
NC Well Contractor Certification Number I HO IL l N I IL r
]S..OUTERCASING'for omntfi cased wells RL Malleable)
_ FROM TO DIAkiL THICKNESS MATERIAL
Y ' ft 3r fL in.
]2ai�Ys Well I fI i�/n�
Company Name R'
-1L^ 16.INNER CASING Olt, ING eothermaldosed-loo
2.Well Construction Permit Al. FROM TO I DIAKETER I TMOCNFss I MATERIAL
List all applicable well cans1nc2(0nJ--1s(Le UlC Counrl;SIM Variance,eta) ft I ft hL
3.VQII Use(cbealtwell use): % ftI.
Water Supply Well: 17:SCREEN
FROM TO D]AMFMR SLOTS= I THICNNESS I MATERIAL
-- Agricultural ctpal/Public ft. ft. hL
Geothermal(Ileating/Cooling Supply) 'Rcsiden"Water Supply(single) ft. ft in.
IndustriaUCommercial DResidential Water Supply(shared) I&GROUT
laigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- ZO ft.
Monitoring CIRecovery ft. ft,
Injection Well: &
A9vif.-Recharge DGrotmdwater Remediation
Aquifer Storage and Recovery Satin Barrier 19.'�/GRAVEL PAC1C(ff9 usable
ItY FROM TO MATERIAL EMPLACnIENT METHOD
Aquifer Test []Stormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) ElTracer 20.DROAMGLOG fattach•additional sheets K
Geothermal(Heating/Coolin Return) F30ther(explain under#21 Remarks) mom To DESCRIMON(color,hardness,sawraclitype,mn sba,etal
ft. 30 ft. piY' Pave
4.Date Well(s)Completed: �^I y Well ID# n• -'00 n f t
Sa.Well Location: % ti•
Perris C-.rvrna ft.
ft
Facility/OwnerName —1 — Facility lD#(ifapplicable) H• ft �: ! e rf
Potoesf y 0, rocs From 17611 Nc-81s crPs'fi�r►.2�flS ft' ft' FEBPhysical tAddress,City,and Zip % ft• 0 7 202?
A5he '21.REMARKS
County ParcelMenti6cat:ionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifcation:—
76.If291s7 N $l .C5Co3 W �
6.Is(are)the well(s)eFermanent or OTemporry Signature ofCertified Well vate
By signing this form,I hereby certify that the ueff(s)was(were)constructed in accordance
7.Is this a repair to an erdsting well: (3Yes or 811,40 with IBA NC(C 01C.0100 or ISA NC AC'01C.0200 Wdl Construction Standards and that a
lfthis is a repair,Jilt out knawn wdl construed lnjormation and explain the nature of the copy of this record has been provided to the iw0mmer.
repair under#21 remarks section or on die back ofthis 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 pmvide 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.
wed: SUBMITTAL 11VSTRIICT[ONS
9.Total well depth below land surface:7200" (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diff—t(example-3Q200"and 2@1001 construction to the following:
10.Static water level below top of casing:j Q� 00 Division of Water Resources,Information Processing Unit,
Ifxaler level is above casing,use"+"
�t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. � (in.) 24b.For Infection Wells: 1n addition to sending the form-to the address in 24a
//�� l above,also submit one copy of this form within 30 days of completion of well
CLe Well construction cab on method:e-) R[)1 t7irb ��m the following:
{r.e.auger,m1azY.cable direct Posh.ate) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of testAff l'1'(• 24c.For Water Supply At Infection Wells: In addition to sending the fort to
�J the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: tP Amount: 0^ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEuvironmental Quality-Divistonof Water Resources Revised 2-22-2016