GW1-2022-02967_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information: ,.\
.S60. l)l+b5Vy\ 4-4.-WATER'ZONES
FROM TO DESCRIPTION
Well Co(n�traetor Name � � � O� � I (Q�
Io93 —� ft. o ft.
NC Well Cantractor Certification Number "15:011TERvGA�IN_tr' ain t7=cased ells ORiVIPiEICZ1r8 itcaDl�
u►, ,\� e ^ 1 I C• FROM TO DIAMETER THICffiNESS MATERIAL
f7lJlJ LJfCa1 ` ft. ft. in.
Company Name C 16 NNER:GASING'OR:TtTB11VGr ¢othe n'tal closed=iuo) sx t� � 8
2.Well Construction Permit#: 4�D� �� J FROM TO DIAMETER TRiCKNESs I MATERIAL
List all applicable well construction permits(Le.U1C.County.State.Variance,etc.) G ft. &3 ft. •,tr In- • S
3.Well Use(check well use):
ft. ft. t0 in. ?�C
Water Supply Well:
FROM TO DIAMETER SLOTSITE TEucKNEss MATERIAL
Agricultural [3Mu al/Public ft ft, in
Geothermal(Heating/Cooling Supply) midential Water Supply(single)
Industrial/Commercial 131tesidential Water Supply PP Y(shared) 48:GROUT. _ :•. .,
Irrigation FROM TO MATERIAL EIVIPLACEMENr METHOD&AMOUNT
Non-Water Supply Well: ft Zt^j ft t P(,`jt.I/C
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19iSi1ND%GRVE;thPAGK :ii" ble +
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft• ft•
Experimental Technology DSubsidencc Control ft. ft.
Geothermal(Closed Loop) [3Traar 20:DRILIJNCLOG eitacbaddlflonalsbeefsif "'
� ..
Geothermal(Heatin Coolio Return) tither(explain under#21 Remarks) FROM TO DESCRIPTION urns bards wvract a siu ere.
6 ft. (03 ft• C iGt v r�u r
4.Date Well(s)Completed:.2— .2� Well ID# ft• ps ft• /1 I
Sa.Well Location:
ft. ft.
�,Z,1,itle.� Nall;na5e
Facility/Ownerl4ame Facility ID#(if applicable)
ft. ft.
9 Robey IJY'•ve- rletcL.uz' 2 NC- d113 �' �'
� R
Physical Address,City,and Zip IL ft' ^4�Fr' >t
u hCl9rv�lJ C 2L REMARKS;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minute/seconds or decimal degrees:
(f well field,one lat/long is sufficient) 22.Certification:
35° Zel i Al•863y99 N?V5 24
t 47.915-V y q IOW
6.Is(are)the well(s)OI eiermanent or OTemporary gnature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in.accordance
7.IS this a repair to an existing well: DYes or o with 15ANCAC 02C.0100 or 15A NCAC 02C P200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarkr section or on the back of thisform. 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'end 2@1001 construction to the following:
10.Static water level below top of rasing: (ft.) Division of Water Resources,Information Processing Unit,
!f warer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:SD• Z (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �" '7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Is— Method of test:J4a�• C01�1?�l rICJL 24c.For Water gunyly&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30,days of
13b.Disinfection type: Civl10'r r2 Amount:127(d completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016