GW1-2022-06816_Well Construction - GW1_20220719

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WELL CONSTRUCTION RECORD (GW-1) r Internal Use Only:
ellContractor Iformation:
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u -' C I�' J lJl 1 168(I) 1 .WATER ZONES
Well Contractor Name F M TO DESCRIPTION
ft. ft.
43�g(� ft. ft.
NC Well Contractor Certification Number 1 .'OUTER CASING for multi-cased wells OR LINER if a livable
a c M TO DLAMETER THICKNESS cable) IL
1 -rn r I1® ft. ® ft- in. ��
Company Name
qq��
1 INNER CASING OR TUBING eothermal closed-loan)
2.Well Construction Permit#• 90C �4 M I TO f DIAMETER THICKNESS i MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): j ft. ft. in.
Water Supply Well: 1711SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public Ii ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 1 ft ft ;n
hidustrial/Commercial Residential Water Supply(shared) 18(GROUT
kri ation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. e r
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19. AND/GRAVEL PACK If a licable_
Aquifer Storage and Recovery Salinity Barrier FR I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20. KILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FR M TO DESCRIPTION(color,hardness,soil/rack e, rain size,etc.)
ME
' ft.
4.Date Well(s)Completed:_1__L 4� Well ID#h ° " ft. t ft.
ft. ft. c
52.Well Lo[c�atpi4yn(� 1�.,`w n
C11 11V�A 1 1 C.� ft. ft.
rity//O.wnerName Facility ID#(ifapplicable) ft. ft.
It7 ft. ft.
P sicaI Address,City,and Zip Fitft. ft.
Y1 p RZ hff— 46066�°15530 r 1DW 21. MARKS
County�``/—F1 _t`P/arcel Identification dNo.(PINS) UC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2Z.Certification:
N W' [-S—
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6.Is(are)the well(s) Permanent or Temporary Si ure of Certified Well Contractor Date
By s ning this form,I hereby certify that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes orX- e-pZplain
o with SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information the nature of the co this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.S to diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay 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 const
ruction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface:-64 (ft.) 24a. or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) consi uction to the following:
6 I
10.Static water level below top of casing: LOO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.#or Iniection Wells: In addition to sending the form to the address in 24a
abov',also submit one copy of this form within 30 days of completion of well
12.Well construction method:i't l 1 R��m ) cons($iiction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f 1 1
FOR WATER SUPPLY WELLS ONLY: i*ision of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
a
13a.Yield(gpm) 7 Method of test: 24c.#or Water Su Dlv&Injection Wells. In addition to sending the form to
the 0 dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
wherq constructed.
Form GW-I North Carolina Department of Environmental QuI�Q I ity-Division of Water Resources Revised 2-22-2016