GW1-2022-06221_Well Construction - GW1_20220620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
/1.gWell Contractor Information:
t.V/�/t G/►'`W/rng Prl`� CO G'G Q /���/�N 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3 � ��� 2 j'ft. 6 � ft. 5��; ✓'L�!'�� �c,r f'�C�L�� ��i¢Nv-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER if a ticable).
FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name
/�qq,�,'� 16.INNER CASING OR TUBING eotherma]closed-lab..
2.Well Construction Permit#: �en Wr � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well corstnvc•tion permits(i.e.UIC.Counrv,State, 4a•iance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial QlResidential Water Supply(shared) 18.GROUT
1ni ation FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring [3R, overt ft. ft.
Injection Well: X M1__� A _x ft. ft.
Aquifer Recharge E3Groundwater R i R I® �,
emediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DISalini flkie'l).n 2022 FROM TO MATERIAI. EM PL:ICEMENT 111 ETHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DS&Sidtdee'C�ontrbl' � ft. ft.
Geothermal(Closed Loop) v1e'QR C;0G'
Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock t e, rain size,etc.
p � ft. J�' ft. C�JC Ot/ P!u+.� �eC �.`d f z
4.Date Well(s)Completed: S-� I -2 L Well U 3, l j- ft. ft. u r 6 w a„ sQ 6'0 I-ILe
5a.Well Location: ft. D fr, rt7 cti r d�y> r&J in
F-ok- ee- &,ffe,y �ESG ft. ft• a J i�/r��� �t�1J�l nP/G� v LrC
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3 o S e 0-5A "J 6y, ,LeX"'�{(
Physical Address,City,and Zip ft. ft.
�1 Q✓J_-5•0 N 21.REMARKS o' / '
County Parcel Identification No.(PIN) !`1.n" v rF� W e J I&ba"'k've X�y O y al
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ���f rr,P��`.G r-�a�Q �� " t v,-
(ifwell field,one lat/long is sufficient) 22.CY';C�24
~e M 1 / r�
,e�4
6.Is(are)the well(s)oPermanent or OTemporary ignature of Certified Well Contractor Date
By signing this forma/herehv ceriffj,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ,nNo with 15.4 NC.4C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill out known well construction in/o•nmtion and mplabt 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 1 GW-I 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: M-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For nutUiple wells list all depths ifd/(ferent(example-3@200'and 2 @/00') construction to the following:
10.Static water level below top of casing: (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
So above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: L 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
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injection 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: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016