GW1-2022-03653_Well Construction - GW1_20220321

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.well Contractor 1 0
O Y t Cl I4WATERZONFS
Well Contractor Name FROM 7'0 DFSCRE'ITON
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NC Well Contactor Certifi/cumber t5..OUTER:CASING fuc OR LWER F
FROM TO DIAMETER THICKNESS MATER�I/AIL
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Compeay Name
/ 1falNNis�C:• OR:.TZ4JB11YG: Closed
2.Well Construction Permit#: ( G> FROM TO I DIAMETER I THICKNESS MATERIAL
List aU applicable weU construction permits(tie.UIC,Country.State,Variance.eta) fL fL I 7O
3.Well Use(check well use): fL m
17
Water Su Well: SCREEN` ..
Supply F
M TO DWNETER SLOT SIZE THICKNESS MATERIAL
Agricultural MM lic fLf fL in
Geothermal(Heating(Cooling Supply) idential Water Supply(single) fc m
IndustriaUCommercial E]Residerttial Water Supply(shared) 11L GRUiTc:..
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: & Q fL cJ JP
Monitoring ORecovery k. fL
Injection Well: -
fG fL
Aquifer Rechaw 13Cttoundwater Remediation 19..SAND/GRIlrY£I TPAC&
Aquifer Storage and Recovery [Salinity Barrier FROM TO r MATERIAL I EMPIACEMEKr METHOD
Aquifer Test• ElStormwater Drainage
Experimental Technology 13Subsidence Control ft
Geothermal(Closed Duop) Tracer 3e DRiLLDYG.LUG.attachaddiRemaldtiee,ff
FrtOM
TO DFSGRiP710N(Color.hasrmes.sdlllrock etc.
Geothermal eatin Cool Rettmm) Outer( lain under#21 Remarks 0 fL
err
4.Date Well(s)Completed: O2 Well ID# 0 fL fc S.4
5a.Well Location: ,�i & fL
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Facility/Owder Name Facility ID#(if applicable) It. R
`l" v y fL & t MAR 2.1 202?
Physical City.and Zap fL fL
V'�l � ri REMAxus
County Parcel Identification No.(PIN) r' "V+tiivr'1 i "I r.''.-•, .,._ :!i'i'
5b.latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/icng is sufficient) 22.Certification:
N W
.72
6.Is(are)the wells) ermaneut or Temporary Sigoacute of Certified Well Conaactor Dace
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.LS this a repair to an existing well: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 WeU Construction Standards and that a
!furls is a repair,jilt out brown well construction iu formation and explain the nature of the COPY o1 this record has been provided to the well owner.
repair under 921 remarks section or on the back of thus form.
23.Site diagram or additional well details:
S.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 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
For multiple wells list all depths#!different(ermnple-3@200'mud 2@1M construction to the following:
10.Static water level below top of rasing: IK� (fL) Division of Water Resources,Information Processing Unit,
Ifwmer level is above cash?&use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection-Wells: In addition to sending the form to the address in 24a
12.Well construction method: v �w-y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,raoaY,cable,lima push,etc.) g'
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test:_ 24c. For Water Sunoly&Iniection Wells: In addition to sending the form to
1 y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �r1 Amount: / 0 Z completion of well construction'to the county health department of the county
where constructed.
Form GW-1 North Carolina Dgmuncnt of Environmental Quality-Division of Water Resources Revised 2-22-2016
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