GW1-2022-03184_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
��l C Scifldelso h 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
y2 ft.
ft.
NC Well Contractor Certification Number 15.OUTER'CASING for mul&eased-wills)OR LINER if a licable)
TO DIAMETER in. THICKNESS MATE_RIAI
Company Name a fL 37 ft J
3� �Q 16.INNER CASING OR TUBING(geothermal clos
2.Well Construction Permit#: -/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) N, ft. in.
3.Well Use(check well use): % ft. in.
Water Supply Well: 17.SCREEN "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]M al/Public g fL 9 9 in.
Geothermal(Heating/CoolingSupply) esrdential Water Supply sin e �� //y 1 Z
pP y) PP y( Ingle) ft. ft. in.
!Industrial/Commercial Residential Water Supply(shared)
18.GROUT "
Irrigation FROM TO MATERIAL EMPLACEMENT
METHOD&AMOUNT
Non-Water Supply Well: R- 2v ft. ' �eyvr�
Monitoring ORecovery ft. ft.
Injection Well:
1t. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK:d I applicable
_Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
_ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary);;
Geothermal(Heating/Cooling Return) j Other(explain under#21 Remarks) FROM rt. rt.TO DESCRIPTION color,hardness,soturock size etc
0 � C fsPn.
4.Date Well(s)Completed: Z Z Z Well ID# %D IL
20 fL a
5a.Well Location: �0 ft 3 ft. S (
Na4k Ge,,zAlez Ae4e-7- 3 fL It. S w e f ogrse S�nrA wllttc
Facility/Owner Name Facility ID#(if applicable) N' ft.
29360 ft
Physical Address,City,and Zip J ft. ft'
Rabe So n /60�0 10 y 31 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) �J 22.Certification- + ' '
0. 00� N /9° Q 522 , W
6.Is(are)the well(s) _ ermanent or EITemporary Signature of Certified Well Contractor Dart(
�,� 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: E)Yes or Egr"' with 15A NCAC 01C.0100 or 15A NCAC 01C.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wills construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: VL) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells Jilt all depths if different(example-3 a(200'and 2@100')
t 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
Cr.
It.Borehole diameter: 1 .in
(� ) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
1 12.Well above, also submit one copy of ibis form within 30 days of completion of well
constriction method:c /�N y(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
(�
13a.Yield(gpm) Method of test: i''-'e 24c.For Water SunDiv&Inie ction 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: 14TP Amount: _� CZ completion of well construction ito;the county health department of the county