GW1-2022-04030_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD`.(GW--1) For Internal Use Only:
1.Well Contractor Information:
Cameron B3ZIn 14.WATERZONES`.
FRONT TO I DESCRIPTION
Well ConttactorName L3 Iw
ft. Z ZS tt
4518-A tt, ft
NC Well Contractor Certification Number 15::OUTER:CASING'formatfi cased wells'ORI:INElt da licatile:•.'-
Ag4a Pd$-Inc. FROM TO D R THICKNESS MATERIAL
ft. 1 (/Jr It in.
Company Name `I
��w� ^��`, f :16. RCASINGURTIJBING:('ebthermalclosed-loo
2.Well ConsicructionPermit#: z V ;6y FROM To DIAMETRIt tmclavEss MATERUL
List all applicable well construction permits(Le.U1C,County,Stare,frariance,etc) ft. ft fn•
u 3.Well Use(check well use): ft ft is
Water Supply well: FROMREI TO DIAMETER I SLOTSUE THICKNESS MATERIAL
Agricultural iDMunicipaUPublic ft, iw in.
Geothermal(Heating/Coohng Supply) residential Water Supply(single) ft ft !n.
- IndustriaUCommeroial Residential Water Supply(shared) I&GROUT '.:.
lrTi ation FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2� .it {
Monitoring DRecovery [t. ft.
Injection Well:- _ ft ft
Aquifer Recharge OGmundwaterRemediation
19.SAND/GRAVEL PACK ffa Ncable
Aquifer Storage and Recovery •fOSalinityBarrier FROM To MATERIAL EMPLACENTENrMErHOD
Aquifer Test DStormwater-Drainage R• ft.
Experimental Technology DSubsideuce Control ft. ft
:DRILLINGLOG attach additional sheets if
Geothermal(Closed Loop) [)Tracer 20
FROM To DESCRIPTION
Geothermal(Heating/Cooling Retum) ;. Other(explain under#21 Remarks) rntor,hardness so;vroek a �fn sIu eta)(' ft ft �&L A�
4.Date Well(s)Completed: '1Z—Well ID# p it' rZ/l S ir'
ft. ft
5a.Well Location:
�- II� il. it l� �".A,tro�R T_i•��"��
L�,9 A NtAJVJ,,�
ft. ft
ility/0� erName Facility Fac
q7 Q' R ft. ft APR 2 q
Physical Address,City,and Zip ft it
S 21.REMARKS
County FParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlongis sufficient) 22.Certification:
4o N 8o• S3Y$t_';'"
6.Is(are)the wells) Permanent or OTemporary Signature of Certified Weil Contractor Date
By signing this fame,I hereby certify that file tvell(s)was(were)constructed in accordance
1.Is this a repair to an existing well: QYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repa r fill out known well constructian information a6d explain the ndfure of the ropy of this iecnrd has been provided to the well owner.
repair under 021 t emarkr section ar on One back of this fornr. 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 1 GW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 2 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3 t@200'and 2Qa 1005 construction to the following:
10.Static water level below top of casing: `/O (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this forest within 30 days of completion of well
12.Well construction method: (101ko Y construction to the following.
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS
,W�ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
139.Yield(gpm) &J Method of test 24c.For Water SunDlv•&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:" O completion of well construction to the county health department of the county
where constructed.
Form GW-I North Caiolina Department of Environmental Quality-Division of Water Resources I Revised 2-22 2016
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