GW1-2022-06188_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
T'Z)k 04 n 14.WATER ZONES
FROM TO DESCRIP ION
Well Contractor Name ft. I G,P
boa4 A ass A'75-ft. I M
NC Well Contractor Certification Num-blerC 15.OUTER CASING for muld cased weds OR LINER"(if a livable
Z��G7 J �n L FROM ft TO' R DIAMETER m. THICKNESS MATERIAL
o IA I scFF yo PVC
Company Name 16.INNER CASING OR TUBING eothermel closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THIC[QVFSS MATERIAL
List all applicable well construction permits(i c.171C,County,State,Variance,etc.)
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
:)Agricultural [3Municipal/Public; 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) g• ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 120 ft. O e_a4- G o9-0
:-)Monitoring 1!� rY�1,
Recove ft. ft.
Injection Well: ft.
ft.
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. -
I :)Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,wflInwk size,eta
Geothermal(Heatin Cooling Return) ,__ Other(explain under#21 Remarks) _
p O ft. ft. Ovet'loar en
4.Date Wells)Completed:Cy"1 b2 Well 1D# P 7 717 1
Sa.Well Location: as- ft. ft. G
ft. ft.
1-fArOn Kr�.mB�
Facility/Owner Name Facility ID#(if applicable) t1• ft. "" '; :"„� �;.
19(o N tj tMcii�CJ Dr. QoAQro NC �7S
uzz
Physical Address,City,and Zip It. ft. J I J l 0 i
(� 21.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minnbes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ;22Z. J1cafio
36, SmZ79S� N _7g. S-TV016 W6.Is(are)the well(s)�ermanent or Temporary of Certified Well C Date
By signing this form,I hereby cerifp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or Bio with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 360 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Qa 200'and 2®100) construction to the following:
10.Static water level below top of casing: a s (fL) Division of Water Resources,Information Processing Unit,
If xuler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �o I�b� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rt• +aC J 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: �f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of best: %2W t1 oro 24c.For Water Supply&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: N T N Amount: 1 iS 02 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016