GW1-2022-06802_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
i
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contrac rName
I 0! r�
iL M
NCp\Well Contractor Certification Number`` 15.OUTER CASING for mullirased wells OR LINER da limhte
Well �I 1l1 FROM TO ii D 1 THICIQiFSS MATE`1RiAL
Company Name14 i t R ,b
p 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: :36 Lt S FROM To DIAMETER i TMCKMS. MATERIAL
List all applicable well construction permits r e.UIC.County.State,Variance,etc.) B. R.
3.Well Use(check well use): B' 1t' I m
Water Supply well: 17.SCREEN
pp y FROM TO DIAhIITER SLOT SIZE TffiCKNESS MATERIAL
Agricultural QMunicipaLTublic 0 ft. ft- in. ,
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) B, ft. in.I I
VIndustriabtCommercial Residential Water Supply(shared) 1&GROUT
n FROM TO hfAgEUAL E6iPLACIIHENI METHOD&AMODNT
r Supply Wcll: . 7j itng Recovery It AoIL
well:
PAquifer;Recharge [3Groundwater Remediation
[]Aquifer Storage and Recovery Salinity Barrier 19.SMND/GRTO L PACK ATERIAL EMPLACEMENT MEMOD
Aquifer Test [)Stormwater Drainage n-_ % i
Experimental Technology DSubsidence Control it. IL
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets if uccessa
FROM TO DESCRII'lYON(color,badness,soHtrock type, size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) vt� ,LL
iL4.DateWell(s)Completed: In �qOZoe�xWellID# 3lotil b$g B•- IJ iu .bru7ns '(/jYi�l1 r ✓'©it.Sa.Well Location: 4 © ' _ rid;�i alnie_k edkt !r a
�^ _
Facility/Owner Name Facility IDO(ifapplicable) fL ve
I��'} y �• 1 11 ek- , G �� fi3 ft- lox' 'L 6r
Physical Address.Ci d Zip _ \-o^Fl P`�
�
C�rax.vt ht. I0o l 0o6 CS VS G
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:
3(Q. 3i s's 3 N 17 S 191
Signature of C ed Well ontmctor Date
6.Is(are)the well(s)&Permanent or Temporary ,
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EgNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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: e
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 construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: to 5 (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi fferent(example-3@200'tmd 2@100) construction to the following
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing:use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LO. (in.) 24b.For Iniection 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: �Z 0��R 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) 10 Method of test: 1 24c-For Water Suppiy&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: mount: 59 completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016