GW1-2022-07135_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor f don:
r• rj 14 WATER ZONES
WellCorrlxa�rName 7' FROM TO DESSCREMON
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NC Well Contras Certifi 'on Number
:I&'OUTER,CAS'il!IC:for•.'rmlti-easedxelts'QRLll!FER if
/ FROM . /To DIAMETER THICKNESS MATERIAL
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Companypany Name •
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rye"^ Y r l6>1NNE1:(hfiII3G•fflR1iJBING:
2.Well Construction Permit#: / 3 // ` FROM DIAMETER THICKNESS MATERIAL
Litt all applicable well construction permits(r.e.UIC,`Cororty,State,Vartance,eta) 1°
3.Well Use(clmckwell use): R. ft I m
Water SD Well: 17t:SCREEN` .:
p FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculturdl 6Zid=WW
lic 0 ft. fc in.
Geothermal(Heating/Cooling Supply) Supply(single) m
Industrial/Commercial 'Residential Water Supply(shared)
„�.�RRotrr.-
Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. vL ^C
Monitoring DRecovery & ft
Injection Wen:
...Aquifer Recharge_._----=- 13Gmundwater Reme diation -
19..SAND/GR&VEL'PAC& Ie
Aquifer Storage and Recovery Salinity Barrier FROM MATERIAL EMPLACEMENT METHOD
Aquifer Test' OStorinwater Drainage fc ft
Experimental Technology 13Subsidence Control Viti, ft
Geothermal(Closed Loop) Tracer 20 DRILi i1KG.'.LOG.attnehadditieaalst»;.
FROM TO DESCRIPTION color,hardness,sonhock . sic,eta
Geothermal eatin Cool' Return) _ Other(explain under#21 Remarks D
/ !e
4.Date Well(s)Completed: - Well ID# /�� iL S-ft- ^ o,
Sa.Well Location: & fL
fL ft:
Facility/Owner Namre/ I 'F Ility ID#(ifapplicable) f & +'% s
2022
AUG
_.
Physical R fL,City,and lap .. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,eme Wong is sufficient) 22.Certi6cadon:
N W
6.Is(are)the wells) ermaneut or Temporary Signature ofCcrtified Well Contractor' I Daze
By signing this form,1 hereby tern,fyi that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well- ®Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Srmrdards and that a
!'this is a repair.Jig out brown well construction reformation and erplatn rite nature of the -py ofthis record has beenprovided to the well owner.
repair corder 421 remerks section or on the back of thisform. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled- �J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ J (f) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifhfferent(esample-3Qa 200'and 2@1003 construction to the following: 1
10'.Static water level below to casing- r
p of mS° (�) Division of Water R i tines,Information Processing Unit,
If water level is above casmt we"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (in) 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
above,also submit one copy of'this'form within 30 days of completion of well
12.Well construction cable, method: construction'to the following:
(i.e.auger,rotary,cable,direct Posh,ca;.) � -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Ini 1 6;on 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: �7 Amount: completion of well construction' to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reso Vfutces Revised 2-22-2016