GW1-2022-06792_Well Construction - GW1_20220715

WELL CONSTRICTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
u— r �aiM S 14.WATER ZONES I
Well Con r Name FROM ft. T D ft. uEscRwnoNM
5�0 n ft. fL 1
NC Well Contractor Certification Number rr n 15.OUTER CASING for mldtl•cased wells)OR LINER Of Ileable
(-f/x�t� FROM fL TO fL DUMETER in 7Yi�CItPIESS MATERIAL
Company Name L —If 0 D V G
L� /} 16.INNER CASING ORTUBING' eothermaI closed4o6
2.Well Construction Permit I �'�1 FROM TO I DIAMETER _ I THICKNESSI MATERIAL`
List all applicable well construction pe sits(i.e.UIC,Coun6,.State.Variance.,etc) it. ft. io•
3.Well Use(check well use): ft. ft. In.
Water Supply Well- 17.8CREEN
FROM TO DIAMETER SLOT SIB THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) rResidential Water Supply(single) ft. ft. in
Industrial/Commcrcial [RResidwtial Water Supply(shared) 18.GROUT
31rtigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, Z a It. kevk+614"tei it1rQ t
Monitoting Recovery ft. ft.
Injection Well:
tt ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL.PACK ifa lieabie
Aquifer Storage and Recovery QI Salinity Barrier FROM TO I MATERIAL. EMPLACEMENT METHOD
Aquifer Test ' [3Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG.attactr additional sheets ifneassa
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) FROM ft. TO ft 'TI DESCRDON color,barduesq,soWrork rains etc.)
CA av
4.Date Well(s)Completed: a'Z Z Weli ID# ft. p ft G
Sa.Well Location: 3b ft. '�,4G ft. f d roc sk
FaciliwdOvnerName Facility! #(ifapp)icable) ft. ft,
r J
' , �Oh Ir D ft. ft. `
Physical Address,City,and Zip ft. ft
I- 21. jut
Ivvv �...GAAtM REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude;in degrees/minutes/seconds or decimal degrees: 1'?''�, '^•�"�n���� n .n...n UNIT,
(ifweli field,one lattiong is sufficient)
22.C tifrcation:
N W f �
6.Is(are)the wells) Permanent or OTemporary Sign fire of/lertifid Wellfcontractor Date
By signing this farm,I hereby certify that the uellls)was(were)constructed in"accordance
7.Is this a repair to an existing well: []Yes or dNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that u
If this is a repair,fill out known 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 i 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-1 is needed. Indicate TOTAL NUMBER of wells constriction details. You may also attach additional pages ifnecessary.
drilled: 1 (,�b SUBMITTAL INSTRUCTIONS
9.Total well depth below Bind surface: 0 t (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd1fierent(example-3Qa 200'cord 2 a@100')•--
construction to the following: ,
10.Static water level below top of casing: 2 a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Servlce 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: Q l r construction to the following:
(Le.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: I W 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es)•above, also shbinit.one copy of this form within 30 days of
13b.Disinfection type: Amount: Z I completion of well construction•to the county healtb department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016