GW1-2022-06890_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use 0111y:
1.Well Contractor Information:
( ll t C,rY) �% fir'�-� 14.WATER ZONES
F'RONI To DESCRIPTION
"'I'll(n1lllJl'Wr NalnC,tj
NC Well Contractor Certification Number 15.OUTER CASING for multi.cased\yells)OR LINER(if a licable)
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Company Nana•
16.INNER CASING OR TUBING(eothermal closed-loop)
2,Well Construction Permit#: FROM TO DIAMKTlgt THICKNESS MATERIAL
h List till applicable ell construction permits(I.e.UIC.Cutanr,State.Variance.etc.) ft, ft. l in.
3.Well Use(check well use): ft. it. i in.
Water Supply Well: 17.SCREEN I
FROM TO DW\IFTER SLOTSI7.E TBICKNE,SS XL\TERIAL.
Agricultural Municipal/Public fl. ft. in-
Geothermal(Heating%cool ing Supply) DResidential Water Supply(single) ft. ft.
industrial/Commercial Q Residential Water Supply(shared) Itl.GROUT 1
Irl anon FROM I To MA FERIAI. ENIPL,\CEMENT METHOD S AMOUN'i
Non-Water Supply Well: ft. ft.
R monitoring QRecovery ft. ft.
injection Well:
a. n.
Aquifer Recharge [3Groundmater Remediation
19.SAND/GRAVEL.PACK(if applicable)
Aquifer Storage and Recovery DSalinity Harrier FROM TO %IX]ERIAL F:DI1'L:\CEM EN'i ME:Tlion
P,AqUiter Test DStotn)w:aler Drainage ft. ft.
Experimental Technology DSLibsidenee Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additicntaLshects if necessary)
Geothermal(Floating/CoolingRetturn) Othcr(explain under?I'_1 Remarks) FROM 1° DESCRIPTIONculnr.hnrdncs[sniVrnckh' cerainsiz/aetc.l
Z'2 �/ l C ft. ft. i"-;C L�'.c. 1-E
eted r J i I
4.Date Well(s)Compl . \fell ID# (T 0 ft' ft'
5a.Well Location: fin ft. Vr-
( >/r //yirc�.hVl�= 2z� ft. ft.
t
F`acilitivlOwnner�N]amc 1J_7 f� Facility ID,(it'applicable) f6 fL
Physical Address.City.and Zip ft. ft. a„r •. J66 1 PROCESS
p-�.� l 21.REMARKS
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Count, Parcel Identification No.(11IN) s e' r~S(F�G� 1 4 b�c.t LeNu 1� 77 r ScLfH rKel
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LU t rn J �� �``� r��'rP P fe T
(ifwell field.one IaVlong is 01 22 C ti
sullicicut) . erfic: n: r
s 357,31 N '�� .. 7fsL���/ W � � � u -zZ
6.Is(are)the well(s)OPermanent or Temporary Signature ol'Certilied Well Contractor—
Date
By signin•G this brie.l herebv certili•thou the uar11L,)was ovre)consiructed in accordance
n 7.is this a repair to a existing\\ell• [Yes or [BNo with 1?:l;VC:I('02C.0109 a'1.5,1 VC,1C 02C.01110 11'ell Omstrui•thnt StundanL,and that a
lfthis is a repair.fill out knoirn well coplwmcrion inlormation and explain the nattere of rile ni{,'of this recarel has been provided tnj ile nrll inviter.
repair under 021 reniarkr section or on the hart•of this form
23.Site diagram or additional will 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 details. You may alsti' ttch es aa additionnl a if necessary.
construction.only I GRt-1 is needed. Indicate TOTAL,NUMBER afwclls pages'
drilled: _. SUBMITTAL INS'rRUC1'I0NS1
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9.Total well depth below land surface: / 0 A) 24a, For All Wells: Submit this form within 30 days of completion of well
Fur multiple meA.c list all depths ifdi/ji•rent(e.rumphr 3@C0t'and 22"A/00) construction to the hallowing: I
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10.Static water level below top of casing: (ft.) Division of Water Res�urees,Information Processing Unit,
if tvater level is ahove rusuki:,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection Wells: fit addition to sending the form to the address in 24a
above,also submit one copy of tlii form within 30 days of completion of well
12.Well construction method: L) construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources'llU id ground Injection Control Program.,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celli -r.Raleigh,NC 27699-1636
13a.1'iehl(grim) Method of test: 24c. For Water SnDPIV&r lnieclim.Wells: in addition to sending the Corn to
the address(es) above, also submitl one copy of this form within 30 days of
131).Disinfection type, Amount: completion of well construction to the county hcatth department of the county
where constructed. fl
Form tiW-I North Carolina Dcpannacnt of 1:11\IrO11n1Clltal(?U811IV-DI,ItiIUII of Water Kl`SOUI'CP., Revised 2-22-2016
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