GW1-2022-04019_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Nee, Alim< 14.WATER ZONES
Well Con c r Name FRONT To DESCRiMON
a �o ft. / ft. 1®
ft. 6Q tt. s M
NC Well Contractor Certification `an Number 15.OUTER CASING for multi-cas wells OR LINER ira licable
,Q 1 r FROM TO DIAMETER THICKNESS MATERIAL
11e 1 ft. 9 ft. im B 1
Company Name /� Q 16.INNER CASING OR TUBING f eathermal closed4
2.Well Construction Permit#: �%'W- n O ' I FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.VIC,Count-,State,Yarlance,etc.) ft. it. in.
3.Well Use(check well use): fit. fit. in.
Water Supply Well: 17.SCREEN
FROM TO D1"IETER SLOT SIZE THICK NFSS MATERIAL
Agricultural unicipal/Public tt. ft. to
Geothermal(Reating/Cooling Supply) Residential Water Supply(single) ff ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lrri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. � ft. 1 i
Monitoring ORecovery ft. ft.
In f ection Well: it. fit.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery C)Salinity Barrier FRONT TO MATERIAL, EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. I ft,
Geothermal(Closed Loop) OTracer 20.DMI:LING LOG attach additional sheets if necessary)
Geothermal(ReatingtCooling Return) M Other(explain under#21 Remarks) I FROM TO DESCIUMON color,baNn soNrock Wpe,gnin size,etc.
ft, o ft.
4.Date Well(s)Completed: '22 Well ID# golt. oo fit --c®r rerk
5a.Well Location, ft. ft.
Zlfit. ft. —
ft. ft.
Facility/OwnerNamc FacilityIDS(if applicable)
t (� aPP ) 6-• i
\/
Physical Address,6ity,and Zip j f ft. ft.
17t7 A Le 6�'/ 1q�`1��! 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/loug is sufficient) 22.Certification:
N W
6.Is(are)the well(s)dpermauent or OTempornry Signature o crtifrcd Well Contractor Date
By signing this forn4 I hereby certify that the iswll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
If llils is a repair,ft//out kiwwn well construction information mid explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the hack of Uiis form.
23.Site diagram or additional well details:
9.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
construc4on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ` "� SUBMITTAL INSTRUCTIONS
J 9.Total well depth below land surface: goo (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffereru(example-3 aC3200'and 2@100D construction to the following:
10.Static water level below top of casing: 2-0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (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: ! / 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
13s.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h rJ-h Amount: ) 'i1 d completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmentai Quality-Division of Water Resources Revised 2-22-2016
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