GW1-2022-03058_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Y-3 73
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING tor multi-cased'wells OR LINER if a licable
d��/ �N" L� FROM ft TO ft DIAMETER in THICKNESS MATERIAL
Company Name
16.INNER CASING-OR TUBING eother a]closed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. we>! It. 9 in. /J �O / ` J&
3.Well Use(check well use): tt. ft. Y in. / l
Water Supply Well: ,17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_A 'cultural Municipal/Publicft. ft. in.
cothennal(Heating/Cooling Supply) .Residential Water Supply(single) ft. ft. in.
:)Industrial/commercial DResidential Watcr Supply(shared) 18.GROUT
ICTI atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' ft. fen�o,7,'� r ,,t 6a/A
' Monitoring ORccovery
Injection Well: 4 w•
Aquifer Recharge nGroundwater Remediation tea✓ �a�
19.SAND/GRAVEL P.ACK'(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
:)Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLINGXOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Re/marks) FROM TO DESCRIPTION 9
color,hardness,soiVrock type,grain size,etc.
4.Date Well(s)Completed: -2-012�Well ID# fe= :� ho l
5a.Well Location://LJ
7 ,/- (T CC!
ft. tt.
Fac/ility/OpwnperName / D Facility
flD/#(if applicable) D ?
L`�D O/� l�u�/ O � � /Cc/• /fCf/� yG �d J� ft. ft.
Physical Address,City,and Zip
e21.REMARKS'':>
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
Gone
Gla�dlongCi�s sufficient) in um
7 Q 22.Certification:
N �lrJ � l/7W
6.Is(are)the wells) ...' ermanent or OTemporary Signature o 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 E' `o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,,ill 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 1 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: it J �D (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: Al (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: J TC� ar 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); Method of test: 24c.For Water Supply&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: Amount: completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1. PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
Test Well to be constructed next to existing school and under future parking loft
No source of contamination within 300 ft
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
Tie variance request form can be accessed online at htto://portal.ncdenr.org/web/vyq/ag£/g�gro/nermit-
gpplications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. iSA NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer,
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal,or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on,my inquiry of those individuals
immediately responsible for obtaining said lnf anon, I believe that the information is true, accurate and
complete. 1 am aware that there are signifrciepenalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree i onstruct,operate, maintain, repair,and if applicable,abandon the
injection well and all related appurten es in accordance with the 15A NCAC 02C 0200 Rules."
ignature of Property Owner/Applicant
�.�SscU Cam_ ti•��r1�
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
tJIMarmal Conductivity Test NotiQcation(Revised 8/8/2013) Pap 3