GW1-2022-03176_Well Construction - GW1_20220307

�A�Jv�SA G/ :I 4`
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infor tion:
7T�
QS 14.WATER ZONES.,
FROM To DESCRI TI
Well Contractor Name
rt rt rot:ore
QN
� ��A �yuft. l OR art.
NC Well Contractor Certification Number 15:OUTER CASING for TO muI"-cased wells OR LINER ifa `livable
T, 4,M e s `A R b� 1U e.'I t)Q 11 J�, /d FROM ft. fL DIAMETER to THICKNESS MATERIAL
Company Name v /
16:INNER CASING OR TU81NG(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consiniction permits(i.e.1/1C,(:orarl)t.Stale, Kw1ance,etc,) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. rt. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) R, ft, in,
Industrial/Commercial D Residential Water Supply(shared) t8.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C2
ft. 0 ft. Q�//Or►,.�� O(/�
Monitoring Recovery ft. ft.
Injection Well: ft. rt.
Aquifer Recharge Groundwater Remediation
19.SAND/CRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
_ Geothermal(Heating/Cooling Return) plain under 421 Remarks) FROM To DESCRIPTION color,hardness,soil/rock e, rain size,ctc.)
Other(ex a ft. f(} ft. 'Redorgq e O
4.Date Well(s)Completed: T e; WeII ID# O ft. /�a R.
5a.Well Location: / ft. ,3 R. Rc f A &�l acAl
Pam' SeS fJ! (" i fL -ter✓/l7 a
Facility/Owner Name / Fac_ility_II/D#(ifapplicable)
n;e4
Phvsical Address,City,and Zip ft. ft.
i+jf._ 2t:;REMARKS
11
CounttV / Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �T .rr S
(if well field,one]at/long is sufficient) 22.Certification- �Ip>�< ;GOA F; UNQ V►►�,
N W o tt
6.Is(are)the wells) rmanent or Temporary Sign ure of ertifi elItractor, Date
ev iv it,tbi.v.Jornt, 1 hcerri/i-Thal the well(.�J wac(were)conclrrtcled in accarddnce
7.Is this a repair to an existing well• Yes or b w hh ISA NCAC 112C.010iA NCAC 02C.0200 Well Consuvclion Slandardc and drat a
/(this is a repair,fill out known well construction it?formalion and explain the nature of the copy o/7hi.v record has been provided to are well owner.
repair under 21 remarks section or on the hack of'Ihis%arm.
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
!•in•maniple wells list all depths iJ'difAwent(example-3 c7200'and?tr 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above caving.use" I 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: G�r'` `� 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) 1 Method of test: l�%/ Uf 24c. For Water SunDly& 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: H r N Amount: N D� _ completion of well construction.to the county health department of the county
where constructed.
Form GW-I North Carolina Departnu:nt of Environmental Quality-Division of Water Resources Revised 2-22-2016
I