GW1-2022-06289_Well Construction - GW1_20220624

WELL CONSTRUCTION RECORD GW-1 F
- r Internal Use Only.
1.Well Contractor Infor/m�ation:e( f
k K E6 l.[n 1 G I e` �� 14 WATER ZONES
Well Contractor Name [FROM TO DESCRIPTION
`t `!rn4�j Re c —�NC Well Contractor Certification Number
( OUTER CASING(for multi-eased wells)OR LINER{if a licable)
5(" n k 9,)Gt I al .C11flQ TnCt M TO DIAMETER THICNEMATERIAL
vv u�. �-L ll yl QLt ft. -15in. VCCompany Name �C INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FRi M 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.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in.
Industtial/Commercial Residential Water Supply(shared) 18 GROUT
ltli ation ` FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring MR.--
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinit Barrier 19. AND/GRAVEL PACK(if a licable)
Y FROM TO I MATERIAL EMPLACEMENT METHOD
rn Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ID Other(explain under 421 Remarks) FR M TO DESCRIPTION(color,hardness,soittrock e, rain size,etc.)
ee���� e�^� ft. t ft. R l�t
4.Date Well(s)Completed: -1 Well ID# ft. �$I 1 �r ���1`
Sa.Well Location: v7 ft. 40�
�- l3'
Facility/Owner Name ��l(���ly Facility ID#(if applicable) / ft. ft.
MCI
Physical Address,City,and Zip
21.1 EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N Wt s r
�6.Is(are)the well(s) ,C,Permanent or Temporary i nature of Certified Well Contractor Date
�"'� 1-.-.,''' By i ling this firm,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No will 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
this is a repair,fill out known well constriction inform nation explain the natm'e o/'the y o'this record has been provided to the well owner.
If
repair under#21 remarks section at-on the back of this forma.
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
constructin,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 7 p (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
1
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use^-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (_Q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
x r�C above also submit one copy of this form within 30 days of completion of well
12.Well construction method, Z construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) t g•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c
13a.Yield(gpm) �� Method of test: 1 24c. For Water Supply& Injection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:A. Amount: � compl tion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qual ty-Division of Water Resources Revised 2-22-2016