GW1-2022-07064_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information: /
/ if 14.WATER ZONES
Well Contractor Name IFROM TO DESCRIPTION
p / /� 2 ft. • " fL
.� {J -�C'7 t' 1 '—.� -�c:. ;.-i,J.�t�
ft. rt.
-vc.'i h..-k"0,- tell G!�
NC Well Contractor Certification Number 15.OUTER CASING for multl-cased wells)OR LINER if a cable'
FROtN TO DL�METER T uCKNFSS MATF.RIAI.
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING( euthermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS \IATF.RIAL
List all applicable it-ell construction permits(i.e.UIC,Comer,State,i oriance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
- AorieuItus4 Mfand(%a;'u i — - - ft. tt. in. - -- --
Geothermal(Heating/Cooling Supply)
IResidetttial Water Supply(single) r __
_ Industrial/Coinrnercial• DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO M EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery R. ft. t
Injection Well:
, d
Aquifer Recharge E]Groundwater Remediation
19.SAND/GRAVEL PAC i a tic I)le)
Aquifer Storage and Recovery, DSalinity Barrier FROM To LENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. rt.
Re
eothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessar
FROM TO DESCRIPTION color,hardness,soillrock tv e, rain size,etc.)
othermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) ft. ft. t.
4,Date Well(s)Completed:6 3 D Z z'Well iD# V"A I C�� � � rt, j?a s rt. / 1 J J �.
5a.Well Location: ft. 0 ft. ��Gr r�� :u ,fl
U/N 4
_ 1: E A MIL" /", (J�}
Facility/Owner Name / q Facility I D8(il'applicable) ye", ft. �`s rt. v t�n ` �-�'O'A-C 63/!!f��t' P.Abv(-7-
Physical Address,City,and Zip ��/ F((_%.ft�S/J D•"�, s�"C ft. ft.
i
21.REMARKS
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: &^' re,,,-e Fr'a,-, C7
(if well field,one lat/long is sufficient) 22.Certification; 0 �� I d"C t- `v e.0" —4,.,f `%�e°-.'
'36, 060 9 Z W
n _ ' fit!Ro�{
_ - - off! - - °
o.is(are)the wt:16)01 ernulne t or ij�lTe'mporary
-- -` .;tx::.�.:,�f`t�cttili:d\i`e!ICc
Br signing(his fin-m./herehr c•ertif),that the we/l(s)was(mere)consirmc•red in accordance
7.Is this a repair to an existing well: DYes or RNo with 15:I A'C',IC 02C.0100 ot•ISM A'C,IC 02C.0200 lfel/Coarm,rctioa Standtrt•tls mind that a
/f this is a repair.fill out known well construction iglbi niation and avplain the nature ol'the ropy gjthis t ec•ord has been prorieled to the well on•ner.
repair under#21 remarks section or on the back gjthis/orar.
• 23.Site diagram or additional well details:
8.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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /1_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (ft-) 24a. For All Wells: Submit this forn within 30 days of completion of well
For multiple trells list all depths iftli#J rent
construction to the following: i
10.Static water level below to of casing: 'a ft.
P g� ( ) Division of Water Resources,Information Processing Unit,
Iftsvier level is above casing,use"F/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61 (in.) 24b.For Iniection Wells: In addition to sending the four to the address in 24a
-��G)/Vi` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 A'lail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: 24c.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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