GW1-2022-06893_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f'
1.Well Contractor Information:G 1(lt/ •' i�7 its r G
14.WATER 7UNF.S I I
FROaI TO DESCRIPipoN
Well(:ontract7or/Namef(
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NC Well Contractor Certification Number 15,OUTER CASING for multi-cased ivells)OR LINER(if a licable)
mom TO DIAMI ISTER THICKNESS MIAT'F.RIAI.
Company Name
16,INNER CASING OR TUI3ING +cidhermal closed-lao)
2.Well Construction Permit#: FROMI To DL\MIr•.Tl:a 'THICKNESS MATERIAL
List all applicable it-ell construction permil.s(i.e.UIC.Coanq•..Stare•.fiu•iouc•d.etc-.) in.
fl. fl. I'
3.Well Use(check well use): rt. rt. it in•
Supply 1Yc1L 17.SCREEN
Water !
F120\I TU DL\:M ETF.R 'I SLOT SIZE TuiCKNF.SS ML\'rER1AL
Agricultural [3Municipal/public R. R. in.i
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Geothemial(IieatingiCooling Supply) Q!Residential Water Supply(angle) rt g• in.I
Industrial/Commercial DResidential Witter Supph•(shared) iR.GROUT I:
In'igation FROM To M)Arr•.RIM. EaIPLACr•.at1:NT Mterllo1)s AMOUNT
Non-Water Supply Weil•
%C ,Monitoring EIRecovery H. ff. i
Injection Well:
ft. ft.
Aquifer Recharge nGroundwaier Reniediation
19.SAND/GRAVEL PAC FC(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM I To I NIXITHIAL EMPLACEMENT%IETHOD
Aquifer Test DStormwaterDrtinage fi. fr.
Experimental Technology QlSubsidence Control
Teothernial
eothermal(Closed loop) ❑iT racer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardnesi,soillroek type, rain Giza Mc.)
(lleatingJC'oolingReuun) Other(explain under,4_'1 Rem:u'ks)
rt. ft• )9,u
4.Date Well(s)Completed: Well iD4 T� C, ft. 3 6) ft• a ! S , _ a .,, / F
1 �
5a.Well Location-. 3 ft. G H• tic/t I r .t�r• 7
1 L rt. H. � :s5
Facility/Owner Name Facility[Do(ifapphcable)
'a�_
7 `� 7 �& r/�'llrxlik ft. i JUL 1 .2022
Physical Address,City,and Zip ft. ft. ii
21.REMARKS
y.C/C Le ytl)0 r
County Parcel Identification No.(PIN) - Well fAAe�rV�G�r'/ �• «� �+,�d����+"� ���.:!
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Sb.Latitude and longitude in degrees/minutes/seconds m decimal degrees: t't..g ro✓� o- - rig m E i��a • �)o}/eth f v7o ,ti
I h b u C L C
I if well field,one let/long is sufficient) 22.Certification:
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3s. 3�7dv 17 N -90.7isyl `jS ,v zz-
� � Z
6.Is(are)the well(s)OPermtment or RITemporary Signature ofC'ertitied Well Contmcw i Dale"
By se"gnitrg this/brrn. I hercln certili•riot the m4lisi was (were)con.sir s,fed to accordance
7.Is this a repair to an existing trcll• Wes or [@No uith/5.1.VCAC 02C.010t or 1 ja VCIC 0?C.02o0 Well Consintrimn S7andan13 and that if
If this is a rcprur.fit/out known+roll rnristntrtion infn matron and et'plain nc�•nature o/the cape oJ'diis record has hrrn prorided tui'the it o+rner.
repair under#21 remarks section or on the back of this/br ni. i
23.Site diagr:un or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use(he"back or this page" to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER ol'wclls construction details. You may also'Atach additional pages if necessay.
drilled: SU13N11'i•TA1,1N97'RUCI•I0NSi.
is
9.Total well depth below land surface: �- A) 24a. For All Wells: Submit this form within 30 days of completion of well
Farr nur/tiple wells list nU depths il'rli/Jrrrrn rrsamph-.ii,i100'and?(,;,low) et)Dgtnlction to the f(illotwimz 1�
l[
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
/fsrarer le+•el is ahoeC rnA rg,use r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. Itor Lliection Wells: In udditi�n to sending the ti)nn to the address in 24a
�17./y,t above,also submit one copy of this+form within 30 days of completion of well
Well construction method: construction ruction to the following:
(i.c.auger,rotary,cable•direct push.etc.)
Division of Water Resources,,Underground injection Control Program,
FOR WA'rE:R SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(,,,pm) Method of test: 24c. For Water SuDDIv C iniection Wells: in addition to sending the Ito 11 to
the address(es) above. also subtrit one copy or this fomt within 30 days of
13b.Disinfection type: Amount: completion of well construction Yo the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of lim irotnncntal Qualny-Disision of Wilier Re,ourcL•,, Revised 2.22-2016
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