GW1-2022-03455_Well Construction - GW1_20220322

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
/Contractor
/�I,�n/J�form/�attiion- ,�y` } y �y� j
1 ,1�ll.l Y•r Vl J v�+t.''.R'FL';F 'LVA�L'�T; ,...•�, ,-E.._ 77
- ?.:
Well Contractor Name FROM ft ft TO DESCRIPTION
ACWC q�d�I �
j� < r`I ft. ft
NC Well Contractor Certification Number
1�S:�.vIJ'1• iGAS1N'G far'�iniilB-casailr'vells 01t: INER lf:"
\:ascade Drilling, LP FROM TO I DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
f6:71YNERCA5ING.UIt. OB11�1G; eothermaGcloiQ400 +.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UlC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 47:?SCRENfs
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
;(Agricultural Municipal/Public 0 ft ft. in.
IGeothennal(Heating/Cooling Supply) Residential Water Supply(single) ft fL in.
Ilndustrial/Commercial Residential Water Supply(shared)
IIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
(Monitoring Recovery ft. fa
Injection Well:
ft ft
Aquifer Recharge ®Groundwater Remediation
19�SANI)1GRAa?f4L AC1 fa lkalle 4
(Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20:DRII L7NG,lI OG attach''additio.*i&ibeets•lC6iecessa �
Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks FROM ft ft To DESCRIPTION color,hardness soittrock type,gmin sae etc.
4.Date Well(s)Completed: _2,,X2-1-4 Well ID# Fur- S66 ft. ft.
5n.Well Location: ft. ft �-�( r a
Facili /Owner Name' t� �, _/ j Facility ID#(if applicable) ft ft 7
'i5 o Die(S' 1 j A t%. L C'tt. . /L/c ft ft
Physical Address,City,and Zip ft. it.
County Parcel Identification No.(PIN) ' 'I
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(il'well field,one IatAong is sufficient) 22.Certification: NC ivc(15 2.�--A
N W -
a -
6.Is(are)the well(s)E3Permanent or Temporary Signature ofCerti6ed Well Contractor Date
By signing this form,!hereby cer16 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ®No with!SA NCAC 02C.0l00 or l5A NCACO2C.0200 Well Construction Standards and that a
!f 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 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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
r�� t
10.Static water level below top of casing: -1'4, (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"i" 1617 Mail Service Center,Raleigh,NC 27699-1617
„
11.Borehole diameter: !a (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: st9 ;e, 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 At Iniection Wells: In addition to sending the form to
the address(es) above, also submit jone 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.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i