GW1-2022-02980_Well Construction - GW1_20220302

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO DFSCRIPTION
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NC Well Contractor Certification Number —ts OVl'ER-CASIIW,W—Mum.—Ciwd�w s`ORT;IIt7ER>
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O DIAMETER TMCKNFM MATERIAL
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Company Name ,� UR';T[1BING(`eothermiil closed=lao
2.Well Construction Permit#: a 1 Lie)II /tp J FROM TO DIAMETER TFUCKNFSS I MATERIAL
List all applicable well construction permits(i e.U1C.County.State.Variance,etc.) ft ( ft• , -2< in- SD R 2 )
1 �-
3.Well Use(check well rise): ft. ft. in.
Water Supply Well:
FROM I TO I DIALV MR I SLOT SUZ I THICKNESS I MATERIAL
Agricultural 13Munic' blic ft ft. tn.
Geothermal(Heating/Cooling Supply) esidential Water SuPP1Y(single)
Industrial/Commercial 13Residential Water Supply(shared) 184:.GROUT
Irri ation FROM TO MATERIAL EMPLACUUMM METHOD&AMOUNT
Non-Water Supply Well: O ft' Z t}t P6U X-
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13GMundwater Remediation
9 SAND/GRAVELPAGH :e'" lore .. , p.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 1IStotmwater Drainage ft• ft•
Experimental Technology Subsidence Control ft• ft-
Geothermal(Closed Imp) Tracer 20 DRILY INGLOG"(attac5'additlonal sheets'itn
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRI rION color,hardness,soilhack tm,gndn sia ere.
ft*
ft. la Z 15vev b u
4.Date Weil(s)Completed: —5—9 of Well ID# 1 S ft• L4 t;C—fL G r' n,k
Sa.Well Location: ft• ft'
-10sco% LabC11C ft ft'
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
(0 39 b jerS Cove FJ NC 2911 ft. ft.
Address,City,and Zip
0 G Ob 9944 2 Cl 8 21:REMaRKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one latilong is sufficient) 22.Certification: DR Ncflo
356 221 41, 64Ib lA N 5 2° 19l AS-02g31LW t :..AMMRkTE8, JGUN
.2-,F- 2 2-
6.Is(are)the well(s)Erermattent or Temporary
By
tore of Certified Well Contractor Date
y 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.0200 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 remarks section or on the back of this 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-I 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: 470 S (R•) 24a, Foral Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100) construction to the following:
4
10.Static water level below top of casing: I�� (ft.) Division of Water Resources,Information Processing Unit,
If Hater level is above casing,use"t" 1617 Mail Service rCenter,Raleigh,NC 27699-1617
11.Borehole diameter: �0• Z (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ff above,also submit one copy of;this form within 30 days of completion of well
12.Well construction method: gollo r`� construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) pp
Division of Water Resourcesl,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test:�a 1• Conhm ne 24c.For Water Sunnly&Infection Wells In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N1 O't*-the- Amount: ^ELIb S 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