GW1-2022-03123_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(�f 14s:WATER ZONES
Well Contractor N me FROM TO DESCRIPTION
3a h i-A y ft. as tt. ��J1 A�
a 3 ft. 1 tt. 1607411a
NC Well Contractor Certification Number / /� 15,OUTER CASING for multi-cased Wells)OR LINER if a' licable
ftn! eS -b xg 6�k2d �R I)I i✓tG I L C_ FROM f. Tu ft DIAMETER in THICKNESS MATERIAL
Company Name
� �7��lD 16.INNER CASING OR TUBING 'eothermal closed-loop),.
S a�
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
l.i.sl all applicable well conslniction permits(i.e.1/16,County.Slate.I/ariance,etc) ft. fL in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETERS SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 R. ft. in.,
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ -irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EJ Recovery
Injection Well:
ft. ft.
DAquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
=
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sbeets if necessa
FROM TO DESCRIP ION color,hardness,soil/rock type, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) b R. ft. Jr? '56,111
4.Date Well(s)Completed: /v/ Well ID# <
ft. ft. r 0i
Sa.Well Location:
rt. ft. rr�i
-1-nhP1ht/ µ. eo1yvt-2JT2 Y12
ft. G�ft. ron' GG
Facility/Ownere Facility ID4(ifapplicable) ft. ft.
_9 3$ r54d +e_ �� i %h eol n � 1 /I/r
Physical Address,City,and Zip
/ 11
{�./Yi�O!►) 11.REMARKS' R 7County Parcel Identification No.(PIN) O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one]at/long is sufficient) 22.Certification: MUM
Pi,
' a
N W
6.Is(are)the well(s)fl?�ermanent or Temporary Sig i ture o ertifie ell Co ractor D e
Hy signing rliis Jhrnt, l he • certify I/ I the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or Vo with 15A MAC 02C.0100 or 15A NCAC 02C.0200 Well Construciion Standards and that a
!f this is a repair.fill out known well constriction information and erplain the nature e of the copy of 1his record has been provided to the well owner.
repair under';21 remarks section or on the hack q/'rhis.fornn.
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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `Ja (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnihiple wells list all depths ifdi11erent(example-3@200'a o`2 a 100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
(f waler level is above casing,use"• •' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: A (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
/^1 \ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Il 0- fwit 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: . �r f 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submitone copy of this form within 30 days of
13b.Disinfection type: Amount: 0?7— completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016