GW1-2022-06892_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only:
1.Well Contractor Information:
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I Jl'(A P- t , ,�n f(� J s- y/ 14.WATER ZONES I I
FRONI TO DESCRI1''I0
Well Contractor Name ft. ft. /Jj
3 76A f1- ft. l i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedtr<e)Is OR LINER if applicable)
( J FROM 1'O DI,\JII•:Phli i rI11CICNI_ss MATERIAL
ft. ft. I in.
J� �
Company Name 16.INNER CASING OR TUBING(geothermal closed-luu
2.Well Construction Permit#t: FROM 'Igo DIAMETER TRICKNUSS n1ATERIAI,
Srur.. Frrinnrr.rr.1 f. iin
Llst nil applicable is-ell consn'u hm perlynts(i.e. C/C,Count. ft.
ft. ft.
3.Well Use(check well use):
17.SCREEN
Water Supph•Well: Fuoat l'U DI:L\II[TEIt SLUT til"!.F TIIICR\ESS \IATERL\L
Agricultural Municipal/Public ft. ft. ina
is
Geothermal(Heating/Cooling Supply) DResidential Water Supply(singlcl It.
I
Industrial/Commercial DResidential Water Supply(shared) 18,GROUT
lrrigalio❑ FuONI TO MATERI NI. F;N1PL:\CEN7EMr N1F.T1100&ANIOUNT
Non-Water Supph \Veil: n. ft. j
Monitoring E]Rccovery h, ff. i
injection Well: ft. f1.
Aquifer Recharge [Groundwater Remediation
19.SANDiGILAl'EL PACK(ifaliplicable)
Aquirer Storage and Recovery DSalinity Barrier FROM TO MATER1,u. F:N1PL:\CF.NIEN"r MET110U
Aquifer Test DStornnvaterDrainage tr, ff.
Experimental Technology DSubsidence Control ft. n.
Geothermal(Closed loop) [DTracer 2111.DRILLING LOG attach Uadditional sheets if necessary
FRO\I E.tiCRI PTION(color.heartiness.s n iUrnck Ir c, rain size.Me)Geolherntal(I'teating/Cooline Reurm) Other(explain faller t121 Remarksl TOf1, if1. (� y /
4.Date Well(s)Completed:L; �LJ `1-� Nell 1Dk rah:. A�1 L,J S D,t') e
f1' tr'
5a.Well Location: ft. /S
Facility/Own it
er Name Facily IDu(il-applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft. r m
rF? ti
y� 1„ 21.REMARKS .•rir+, rn
ec
County Parcel ldcntif+cation No.ll'lN1 C st?: 'd i C' ,�C��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lan'Inng is sufficient) 22.Certification: c
3s 3sG �'� i N -�D-7/33Q
6.Is(are)the well(s)OPernianent or Temporary
Signature ol'C•erlilied Well Cuntractorl Dale
,
liv signing flue Jame,I herehr cerfili•'thu t/tirelu.%)aura'ovvre)consa-ucted tit uCrordaner
7.Is this a repair to in existing well: QYes or WNo reith 15A NCAC o?C'.nlnn or 15.4 yC,l(:'n2C.o2(io wt.11('onsnvction Stundards unit Mara
ifihis is a rc7)nir.Jill oar kno+rn null rona'rrucrinn inlnrxrarion unit trp/rrin tilt annul•uJ tilt ri�n'afthis record has been provided ii,the well on ner.
repair ender 221 ,tPniwk,section ar an the back a)this loco,. 23-Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wellconstruction details. You may also attach additional pages if necessary.
construction.only I GVV-1 is needed. Indicate TOTAL.NUMBER of wells I;
drilled:------- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / y -(ft-) 24a. For All Wells: Submit this•tone within 30 days of completion of well
Fur nudriplt„a•!Jc li,r all dtpihs r,'(dJ]crrnr area up1,•-.f{ft?00"u,td 2( ldf11 construction to the R)Ilowing: II
10.Static water level below top of casing: ��� (ft.) Division of Water Resources,Information Processing Unit,
It"'arse Joel is ahovt(asing.use'•,' 16,17 Nlail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241). For Injection Wells: In a(IIdition ft)sending the form to the address in 24a
above,also submit one copy ol'i'this form within 30(lays of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary.cable,direct push,etc.l
Division of Water Resources,I
nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16:36 Mail Servic E Center,Raleigh,NC 27699-1636
13a-yield(gpnQ Method of test: 24c. For Water Surmly&injection Wells: In addition to sendim;the form to
the address(es) above, also sulinlit one copy of this.fonn within 30 days of
13b.Disinfection type: Amount: completion of well construction tit the county health department of the county
where constructed.
Form Ci1V-I North Carolina Depanuum of E:nsironmental Quality-Dis tsron of\Valet Resou I rce6
Revised 2-22-2016
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