WI0700458_Well Record_20220714

WELL CONSTRUCTION RECORD (GW-I)
1. Well Contractor Information:
SQ\( G(.((
Well Contra for Name
r-21g --A
,.0 Well Contractor Certification Number
Compaq Name f [�
2. Well Construction Permit #: V\!�I_ `�� &Pi
List all oppticabk well construction permits (i.e. UIC. Count,. State. Variance. etc.)
3. Well Use (check well use): -
Water Supply WeI1:
Agricultural
DGeothcrm:al (Heating/Cooling Supply)
DMus-trial/Commercial
lIrngation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge.
Aquifer Storage and Recovery
BAquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Hcating/Cooling Return)
�Municipal/Public
O Residential Water Supply (single)
O Residential Water Supply (shared)
EtRecovery
▪ Groundwater Remcdiation
0Salinity Barrier
Q Stormwatcr Drainage
▪ Subsidence Control
o Tracer
0Other (explain under #21 Remarks)
4. Date Well(s) Completed:
Well ID#
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
) FWft.
Jh,',1fCft.
Vft.
ft.
15. OUTER CASING (for muld-cased welts) OR LINER (if ap llcabie)
FROM
TO
DIASIETER
TntCKNFSS MATERIAL
ft.0 ('i ft.
a. in.
SC- S_%,\ isFl Va c,
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
la.
17. SCREEN
a Trtl'L•S.CCe 1 MMA7i:irrsr_
5a. Well Location:
XewV
iacitityfDwner Name Facility 11)1(if applicable)
Li mI\ Ghttol\ C.
Physical Address, City. andiZip 7881
15EcaU oS f
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field, one latilong is sufficient)
35`'3-7, cS6 N C 1 �3.,3�
6. Is(are) the well(s) JPermanent or jTemporary
7. Is this a repair to an existing well: QYes or INo
"this Ls a repair. fin oaf known wen construction informative and explain the nature of the
repair rmder 821 remarks section or on Me back of this fonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction. only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths "different (cranrple- 3[d5200' and 2@ 1011)
10. Static water level below top of casing: cT j
"water level Ls above casing. use "
11. Borehole diameter: (in.)
12. Well construction method: rt.') aC�
(i.e. auger. rotary. cable, direct push, etc.)
1,20
Dna►1ETER St-OTSF7E
0
ft.
ft.
In.
ft.
in.
(ft.)
(ft.)
18. GROtTI
FROM
ft.
fit.
TO
taof'
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
ft.
MATERIAL
EMPLACEMENT METHOD
ft.
IL
20. DRILLING LOG (atta h additional sheets 1f necessary)
DESCRIPTION (cater. hardness.salI rocs type. grain slre. eta)
FROM
0 ft.
)5 fit.
'4 6".
ft.
TO
1s ft.
ft.
ft.
-75 fit.
0.
S0, ft.
mEc. ¶ ncl.
maQ_ ud or d
0,6 fit•
ft.
rock�SA1c-
21. REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) - - Method of test:
13b. Disinfection type: Amount:
22.Certificatioon:
ahsti=-t--
Sfs.�r�tu of Certified Well Contractor
By
signing this form. 1 hereby cerlh• that the well(s) was (were) constn cted in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC OZC.0200 Bell Construction Standards and that a
copy of this record hat been provided to the wdl owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. For lniection Wells: In addition to sending the form to the address in 24a
above. also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnis & lniection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Date
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2.22-2016