GW1-2022-06831_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
14.WATER ZONES ( I
Well Contra or Name
FROM TO DESCRIPTION
36o L 3(-S a- t Ira
15 Lk S bn. S-k9-
N'C NVcH Contractor Certification Number` ` 15.OUTER CASING for mull se ells OR LINER tf a livable
j-` 11 l V'�1 11`1 V� 1 Vi L, FROM TO DIAMETER 1IIICKNESS 1LITERLIL
Company Name W I..r R. �,`7 tt. r_LJ t/ in. I _(9)10
_GGtl 16.INNER CASING OR T[IBING(geothermal closed400 )
2.Well Construction Permit#: S -1 S $ FROM TO 'DLAMETER THICKNESS I 1%1ATERIAL
List all applicable well construction permits(t e.&W,Cotm(i;State,Variance,etc) rt fL in..
3.Well Use(check well use): tt' tt 1-
Water Supply Wcll: 17.SCREEN
FROM TO DIAAIE FR' SLOT SIZE TIICKNESS MATERIAL
Agricultural E]Municipal/Public 0 ft. (t, in.
Geothermal(Heating/Cooling Supply) E@Residcntial Water Supply(single) ft. fL
Phidustrial/Commercial [DResidential Water Supply(shared)
18.GROUT I
f-Ift-rigation FROM I TO '51ATERML EUPLACENEENT METHOD&AMOUNT
Non Water SupplyMlcll: tt 3 tt lk►v�e�t t�ktn e
Monitoring QRecovery
Injection Well: - t t L
PAquifer Recharge DGroundrvater Remedialion H
19.SAND/GRAVEL PACK(if applicabl➢f e) t
[3Aquifer Storage and Recovery [3Salinity Barrier FROM TO ATEMAL EMPL.lCEMENT I%WMOD
(Aquifer Test []Stomtwater Drainage 11:' ft. ,
Experimental Technology ❑1Subsidence Control
i
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(1 Ieating/Cooling Return) nOthcr(explain under 1121 Remarks) FROM TO DESCRIPTION(color,hardness•sog/rock type,grain ske,etc)
H. 0 rL Sa /
4.Date Well(s)Completed: Well ID# LID ft Ij o ft- yl
5a.Well`Location: tt- f -fl_ '
Iy• 1�C 1 fh O)It S fL ft_
Facility/Otvner Name Facility IDI(if applicable) M ft-
ft. rt_
Physical Address,City,andZip tt_ tI .
r 21.REh1ARKS t
yaS( ce, U"AOAO �vv: =�tlltFt
County Parcel Identification No.(PIN) nr�� �n 11
7tit` ii9uti11 jl%i Fin,. •�-. •,,vim
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one faulting is sufficient) 22.C titivation:
3�. 2-1 ©`l 9 N rJ Ss� 3 n �3 W
6.Is(are)the well(s)OPermanent or Diemporary Signat irelof'Citified Wed Contractor Date
By signing this form,I hereby certify that the well(s)it-as(were)constricted in accordance
7.Is this a repair to an existig w _nell: [DYes or [NNo with 15ANCAC 02C.0100 or 15ArVCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out(mown well construction information and explain the nature ofthe copy ofthis record has been provided to the well ou=ner.
repair tinder'21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� (ft-) 24a. For All Wells: Submit th s form within 30 days of completion of well
For multiple e•ells list all depths ifdierent(example-3©200 and 2@100) construction to the following.
10.Static water level below top of casing: 'i b (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use. 1617 Mail Service Fenter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.Tor Injection Wells: hi addition to sending the form to the address in 24a
p _�Q� above,also submit one copy of This
12.Well construction method: A 1 e f—� form within 30 days of completion of well
construction to the following:(i.e.auger,rotary,cable,direct push,etc.) I
I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
2 � I
13a.Yield(gpm) Method of test: l 24c.For Water Suapiv&Injection Wells: In addition to sending the form to
` the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount fJ Z completion of well construction toI 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