GW1-2022-06676_Well Construction - GW1_20220708

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: "
i
1.Well Contractor Information:
/t I/ ��/ (n /'� t✓��r ✓� �� i'°'" �� 14.WATER ZONES
t FROM TO DESCRRI1PTIO 1
Well Contractor Name ft.
71,;, ft. ft. ' a
NC Well Contractor Certification Number l5.OUTER CASING for mold cased wDUB)OR LINER if a lfcable
FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n, ft. in•
List all applicable well coustroclion permits(i.e.VIC,Cowav,Slate. Variance.etc.)
id
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
FROM TO MATFRIAI. F.h1PLACF,MF.NT METHOD&AMOUNT
Irrigation
ft. ft.
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DiSalinity Barrier FROM TO MAl'F,RIAI. F.MPL:�CEMENT MF,THOD
Aquifer Test DStonmvater Drainage ft. rt.
Experimental Technology oSubsidence Control n, ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessar
FROM T(t DESCRIPTION color,hardness,soil rock e, rain size,etc.)
Geothermal(lieating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 26, Well I D# e ft. ft.
5a.Well Location:
LZ
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
Physical Address,City,and Zipif 2t.REMARKS rut'fv:is fc^^✓ v' tSt
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��C 1r l �L s [N r s �,'W Nr' rG�t r
County Parcel Identification No.(PIN) S�' / cam:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
e,6P�f�,I.;
(if well field,one lat/lung is sufficient) 22.Certification: ,
Signature of Cenrfied Well Contractor Date
6.Is(are)the wells) Permanent or Temporary
By signing this fin-in.1 herefrr certifi•tha I re well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo u•ilh 15.4 NCAC 0?C.0100 or 15A,VCAC 02C.0200 Well Consn iedan sram+tn ds and that a
If this isa repair.fill out known well constriction inJnrmalion and e.rplain the nature o/'the copy of1his record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis fm-,n. 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'
,e)
9.Total well depth below land surface: (ftJ 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/di/ construction to the following:
a
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.nse"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: (in.) 24b. For Infection 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
12.Well construction method: C"> ✓i 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 subtitit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction Vito the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources