GW1-2022-04003_Well Construction - GW1_20220425

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WELL CONSTRUCTION RECORD(GW4) For Internal Use Only:
1.Well Contractor Information:
) �Qlf l 1 i�.� G�1 �5�f1 14. ATER ZONES
FRC I of TO I DESCRIPTION
Well Contractor Name
ft. ft.
LJ,C1N� 436M ft. ft.
NC Well Contractor
Certification Number �j c1 fffttt��� 15. UTER CASING for multi-cased wells OR LINER if a livable
1 1 W��t 1 C 1 1 1 cy ft. TO t ft. DIAMETER
'r in. THICKNESS MATERIAL
oec7 r Y
Company Name11-IJ 16. NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FR TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FRC M
REE TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural Municipal/Public it.
ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in,
hrdustrial/Commercial Residential Water Supply(shared) 18. IROUT
Irrl ation FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. to-WRC-r coy CI
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 11
19. /GRAVEL PACK if a livable
Aquifer Storage and Recovery E]Salinity Barrier FR TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage I ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets if necessary)
FR TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) rfftt
t ft.
4.Date Well(s)Completed:L-+—�C� Well ID# ft.
5a.Well Location: ft.
� . _i ft.
Facility/OwneerNaine Facility IID#(ifapplicable) f,
- A( 1o)Qn
ft, ft.
Physical Address,City,and Zip ft. ft.
(lnR4J ri( A�l�l� 21. MARKS
County a Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22, ertitication:
• t r� rr
N W M"_I`i.—aZ
6.Is(are)the well(s) Permanent or Temporary Si ore of Certified Well Contractor Date
By s ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or wi A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatioplain the nature of the opy this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.S ite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You ay 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 cons ction details. You may also attach additional pages if necessary.
drilled: SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface:� Q( (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diifferent(example-3@200'and 2@100') cons ction to the following:
10.Static water level below top of casing: 381 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: L2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
a above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: -1 const ruction.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
t;
13a.Yield(gpm) 00 Method of test: A 1 a 24c. For Water Su I &Injection Wells: In addition to sending the form to
the a ddress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:41 Amount: d coml letion of well construction to the county health department of the county
wher,constructed.
Form GW-1 North Carolina Department of Environmental Q lity-Division of Water Resources Revised 2-22-2016