GW1-2022-03525_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I�.�t��ilti1� ��/ hAr°f �y , l G 3[Ott1/ IJ�• /r•✓Lj 14..WATF.R7oNES
'TI FROM TO DESCRIPTION
Well Contractor Name ft. ri.
7o ft. ft.
R LINER If a Ifesble
NC Well Contractor Certification Number Is.OUTER CASING for multi-cased wells O
FROM TO DIAMETERTnICKVFtiS MATERIAL.
C. /J ft. rt. in.
Company Namc 16.INNER CASING ORTURING eotttefmal dosedallo
I�!i�o FROM TO DIAMETER THICKNESS MATERIAL.
2,Well Construction Permit#: , / ✓ rl
l.isl till nppficable well connt srClian permits 7i,e.VIC.Caunps Steve.I@trionce,ele.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SI.OTSIZE TIIICKNESS 11ATFRIAI.
Agricultural Municipal/Public ft- ft. in.
Geothermal(HeatinK'Cuoling Supply) [IResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [31tcsidential Water Supply(shared) 18.1g,GROUT
TO MATF.RIAI F.?1 PLACFMF.NT METHOD&AMOUNT
lrrl attOn
Non-Water Supply Well: 0 ft- 36 ft-
Monitori»g rlRccwvery ft. R.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Reniediation 19-SAND/GRAVEL PACK(if a Ilcahle
,Aquifer Storage and Recovery oSalinity Barrier FROM ft.. TO atnrEwnl. EnIPI•ACP•MENT METHOD
Aquifer Test oStormwater Drainage
tr.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.11RILLING LOG attach additional she if necessary
. TO
FROM DESCRIPI'101 color Mtdnns,snlVrock t e- min size.Ha.
Geothermal(I[eating/Cooling Return) F30ther(explain under 421 Remarks) o ft. 15' ft. e �:I' f
4.Date Well(s)Completed:2—/7 2-2-woiID# GGt—�0 C �� ft' �5 ft. (�ra�', touNJ 4 C1�`
5a.Well Location: ft. 3 O ft- a. ft) %�L C/a _f 1 re��
W11Y 101 �7� JO�u�rcu3,TitL,
Tr
FucditylOwner Nome Facility IDV lit applicable)
Sta fest Jle ft.
.3 2-/D Thy�or3'V% le�l w' —�'/V C 29 G 7 7 rl. rr.
Physical Address,City.and Zip
21.REMARKS `
J^e J G��
r lie '� a.afl otv�© u!>d, o•:r
Count' Parcel IdentificationNo.(PIN) ltcu fe��� ��o�
vM Q ./1/Loo.,tC r>eA i'v O-
Sh.eil Rude and longitude in degrees/minuteslseconds or decimal degrees: 7,Q t o ff`r �"e-/.N C
t dwell field,one iaVlong is sufficient) 22.Certification:
Wcr.tifi1',c::dZW`clI
Q�/Q_J`/art'i�A/.
gnature o Contractor Date
6.Is(are)the well(s)OPermanent or Temporary i✓
By signing IN.,Jo nt,l hereht•rerli(i•(hn,The;,/Its)w•a.+'ltv✓rr/eorromtered in accvrdanre
7.Is this a repair to an existing well: Oves or MNo with 7J.4,vC4C'n2C.ornn or/5,I,VC.4C n2C.n2on Well Cnush"ction Stan&nw,antd chat a
It ihis is a rdntir,ill our ktrntcn inlnrntativa un&rxplain the,nauu•e of the
cnpe of dtis ri•mr-d has been provided u,tln"well an•ner-
repnn-uatler 021 rentnrk,sertirot nr un the hack of this din-, 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8,For Geonronly I G ur is n Closed-Loop I Geothermal Wells having the same construction details. You may also attach additional pages i f necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER o1'wclls
drilled;__ SUBMITTAL INSTRUCTIONS
9.'Pntol well depth below land surface: 3 6 (ft-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
F'nr ondliple tvellc lie,au daluht ifdilli•renr a+xanrp/i-.+C-2nn'nn<t 2 /nn't construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/(Darer Irve1 i.r nl nrr raving."M." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ✓ (in.) 24h.For Injection 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: Sn IVI_LI - construction to the following:
ox.auger.rotary.cable,direct push,ctc.l
Division of Water Resources.Underground Injection Control Program.
FOR�l'ATER SUPPLY WELLS ONLY:
1636 Mail Service Cei ter.Raleigh.NC 27699-1636
13a.field(gpm) Method of test. 24c.For Water SUDDI\'& Infection Wells: In addition ut sending the form Io
the address(cs) above. also submit one copy of this torn within 30 days of
Amount: completion of well construction to'thc county health department of the County
13h.Disinfection type: where cunstntcted.
Form Gw-I North Carolina Department orCnviromtnmtal Quality-Division or water Resources
Revised 2-22-2016