GW1-2022-06830_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD(GW 11 For Intemal Use Only:
1.Well Contractor Information:
A r L l- 14.'WATER ZONES I
Weircontr4tor Name FROM TO DESCRIF371RN
�� ft. 3-u% V 1A I'7
ft. &
NC O
Corttrsctor Certification Number 15.OUTER CASING ntdtt eased wdU OR LINER Ittable
Ne, W4,11 it FROM TO DIAMEM THICKNESS MATERIAL
Oft. fL • ln. c
CompanyName `'�
g ' '' o 1 3 fi " 7,0.2-2. 16.0.mR C OR
TRING thermal ci 0204 a
2.Well Construction Permit#: �y�] yp FROM To DuntETER TffiC1tNESs MATERWL
List all applicable well construcdonpermits(i.e.UIC.Count};State.Variance,etc.) ft. fL io.
3.Well Use(check well use): ft. IL in
Water Supply Well- 17.8CREEN
FROM TO DIAMETER SLOT SMLE L TiQCKNESS MATERIAL
Agricultural unicipal(Public IL ft, 16.
Geothermal(Heating/Cooling Coolin Supply) Residential Water Su 1 sin le I(R $ pP Y) pp Y( 8 ) ft, ft. hL
Industtial/Commerciai Residential Water Supply(shared) 18.GROAT
Irriwfion FROM TO MATERIAL EMPLACEMENT Tn0D&AMOUNT
Non-Water supply well: fL ;L 0 iL 2
Monitoring Recovery ft, ft.
Injection 1:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier19.SAND/GRAVEL PACK lteabi
Barrier FROM TO MATERTAL EMPWCEMENTMETHOD
Aquifer Test OIStormwater Drainage % ft.
Experimental Technology Subsidence Control
I'
Geothermal(Closed Loop) D'hacer 20.DRII:L1f1G LOG:attach additional sheets Unewsary
Geothermal eatin Coolie Rerun) Other ex lain under#21 Remarks FROM To DtSCRtFTroN wtor usrdu coiUrock n e ere.
0 ft. o ft G
4.Date Wel(s)Completed: Al Welt ID# f662 fL
SR.Well Location- ft• %
- - - --- - -- - - - ft.
fiaellity/Owner amo !! Facility 1D#(ifapplicabte) fi• ft
ft. w
ft. ft..
PhysicalAddtrss,City,and Zip fl ^ ft.
NIi
County Parcel Identifleadon No.(PIN)
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(ffwell field,one lat/long is sufficient) 22.Certification:
4
6.Is(are)the wells) Permanent or 13Temporary SJandEn of rtilled Well Contractor 1 Date
By signing t is form,I hereby c-Iry that the it-e/f(s)was(here)constructed in accordmtce
7.Is this a repair to an existing well: E3Yes or 040 with 15A NCAC 02C.0100 or 15A MAC 02C.0200 Well Construction Mandarrls and that a
If this is a repair,fill out knmvn well construction it�ormation and explain the nature of Die copy R1�tlds record kas been provided to the well owner.
repair under#21 rmwks secdon or an the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Webs having the same You may use the back of this page to provide adtditional:well site details or well
construction,only 1 GW 1 is needed Indicate TOTAL NUMBBR of wells construction details. You may also attach additional pages if necessary.
drilled:_1 SUBMITTAL.INSTRUG°I I,(DNS
9.Total well depth below land surface: o (fL) 24a.For All Weds: Submit this' within 30 days of completion of well
For multiple wells list o11 depAta tfdl/)erertt(example-3QZ00'and 2®100) construction to the following:
10.Statle water level below top of casing: �� (ft.) Division of Water Resou I ces,Information Processing Unit,
(J rater level is above casing tare"+" 1617 Mail Service Ceuti,Raleigh,NC 27699 1617
11.Borehole diameter: (in.) ?rib.For Infection Webs: in addition to sending the form to the address in 24a
:_ Q i r q i/(1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:12 auger,rotary,cable,direct push etc.) �� -, constmetion to the following:
Division of Water Resources,Underground b jection Control Program,
FOR WATER SUPPLY WELLS ONLY-
I `-I 1636 Mail Service Cent r,Raleigh,NC 27699.1636
13a.Yield(gpm) 10 : Method of test: � °o UV 24c.For Water Sumsiv&.In fecjltin Wells: In addition to sending the form to
the address(es)'above, also sdbmit'one copy of this form within 30 days of
13b.Dlsinfeetlon type: Amount: completion of well construction to the county health depattdateut of the county
where constructed.
Form GW 1 North Camliaa Department ofEavinownental Quality-Division of Water Resources Revised 2.22.2111 t;