GW1-2022-04148_Well Construction - GW1_20220425

`".1 1'll it'1-VI 111
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ETI C S�We j jo N - _14r WATER ZONES:
Well Contractor Name FROM TO DESCRIPTION
�I I/V ft. (�^p ft.
ft. )/U ft.
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased`wells)OR LINER(if ii Iicable
5 ��t13Dt�5 Ul/0 tr n�to//I n 5 FROM TO DIAMETER THICKNESS MATERIAL
(J ft. 0 5 ft. in.
Company Name
�� 7�Y 16 INNER CASING OR TUBING cothermal closed-loii
2.Well Construction Permit#' FROM TO DIAMETER, THICKNESS 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.
Water Supply Well: -17.:SCR MEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- Agricultural 6��sidetial
ublic cl5- ft. /0 S ft. Z in- 1 2-
Geothermal(Heating/Cooling Supply) Water Supply(single) It. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUP.
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C7 f4 2 U f4 Sf} �C+" [rla
Monitoring Recovery It. ft.
Injection Well:
_ ft. ft.
Aquifer Recharge QlGroundwater Remediation
_ 19.SAND/GRAVEL PACK if a licable_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLINGLOG'attach additional sheets if-necessa '
FROM TO DESCRIPTION(color,hardness,soillrock t, 'n size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. /0 fL %o.P So.'l Cl 9rAV,1
4.Date Well(s)Completed: U�/aZU 2 2 Well ID# 10 fL 10 fL 5 A, (/'u, X I//
5a.Well Location: Zv ft. [/� fL /�,rd /,7 r-wn C/
�A 1.5��� 4(kle<' r 2'0o ' 7,/- yo fL 5 ft J4kl`e I SGvd &t WLI1c
Facility/Owner Name ) Facility ID#(if applicable) 5 o ft. if) ft C�a 1 /IG t I� hl rt
Pjc'ecl o 0 (/e �u ft. //v It-
Physical fL S an•1n(/ {i i� �i�i<.;n Gv�1�
Physical Address,City,and Zip 4
REMARKS -77 a
Ro1vleai 3 �3 0 3 -of - OGD 21 7
County Q'^ Parcel Identification No.(PIN) m
{(J
Sb.Latitude and ongitude In degrees/mina es/econds or decimal degrees:
22.Certification:
(if well field,one laUlong is sufficient) ` S vl IZs�'"-�t`'/"•'„" "�=?d•i,rl j
�y ° � �_ Z N �72 ol9- V 86 w
6.Is(are)the well(s) ermanent or DTemporary Signature of Certified Well Contractor Date
/ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or DK- with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knowm well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: Q 9 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"// 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: k> (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/� rr/nt'y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rl�T �'ti Q(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
<
13a.Yield(gpm) �(] Method of test: Ay'll �i t 24c.For Water Supply&Infection Wells: In addition to sending the form to
,Y r/4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 O c- completion of well construction to the county health department of the county