GW1-2022-02989_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W ntractor Information:
l rL •1a.WATER ZONES>.
FROM TO DESCRIPTION
Well Contractor Name ft. 2 q
ft. ft.
NC well Contaactor Ceecifiaatim Numb= rIDDIn" wells 4.Imm lLcale
FROM TO DIAMETER THICKNESS MATERIAL
Company Name U ft. R. I in. R--
I&Ile R CASING OR TUBING thermal dosed-loo _
2.Well Construction Permit#: mom TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft- ft. in.
Water Supply Well: FROM
SCREBN;
PROM TO DIAMETER SLOT SITE THICBNESS TERIAL
Agricultural E3Munt blic O ft. Ft ;m
Geothermal(Heating/Cooling Supply) idential Water Supply(single) f,. ft. in.
_ industrial/Commercial Residential Water Supply(shared) I&GROUT P
Walition FROM I TO MATERML MACENIMTr METHOD do AMOUNT
Non-Water Supply Well: ft' 5 ft �®
Monitoring "ecoy ft. ft.
Iwection Well: ft. M
Aquifer Recharge DGroundwaWRemediation
-19:sArroIGRAVEi4RAGE(itappliceilile,
Aquifer Storage and Recovery 13Salinity Barrier FRoM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Stormwater Drainage ft• ft
Experimental Technology 13Substdcnce Control ft. ft.
Geothermal(Closed Loop) EjTracer 21 DRII.LING LQG attach additional streets if
Geothermal eatin Coolin Return Other(explain under#21 Remarks) FROM TO DESCRiPnON color hudoem 50111 otk etc.
ft. ft.
4.Date Well(s)Completed: 'qyl- Well ID#
5a.Well Location: ft. ft.
ft.
ft. ft. -
Facility/Owner Name Facility IINi(if applicable)
nee .5-�mrP, � � � I,f��-;li
physical Address.City.and ft. ft. " r�riuF 1 ,a �^-w+C Jfv;
QP f 1 .21.RBIMAR>;S
,sty parcel ldentificatim No.(PIN) �� ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well fleld,onnee lallong is sufficient) 22.Certification: j
L�(n D2-`1 1N 2fL)1. 3�t4 w 71 J'o- ll ill .�
6.Is(are)the wells) rmaneat or 13Tempomry signature of Certified well Contractor Hate
Of
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 'C.�t es or ONTO wirh 15A NCAC 02C A100 or 15A NCAC 02C 4200 Well Construction Standards and that a
If this is a repair,fill out lototvn well construction Information and explain the nature of the ropy 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:
g.For Geoprobe/DPT or Clod-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details..You may also att eb additional pages if necessary.
drilled: 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !i (fQ 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differew(ea»mple-3Q200'and 2®100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 1 (in.) 24b.For Iniection 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: 00' v t7 construction to the following:
(ie.auger,rotary,cable,direct push,etc.)—�
Division of Water Resources,Underground L>3ection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matti Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Method of test: M. 24c.For Water Snouly At Lai action Welts: In addition to sending the form to
L " l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ 1 �J Amount: ti completion of well construction to the county health department of the county
where consweted.
Fonn OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016