GW1-2022-07136_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor]Information:
-To k r, 6`i-4en 0'14.,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name S ft- ft.
3oQy A It. tt.
NC Well Contractor Certification Number `,15.OUTERCASING(for multi=cased wells)OR LIIVER'if-sp Ileeble ,
�0.`4
( FROM TO DIAMETER THICKNESS MATERIAL
G�r w i 2A�c^�.s /1 L Company Name 6 ft. 44) ft. (v y in. 5 P v c.
�t �/ .16:INNER CASING OR TUBING:(geothermal closed-loo
2.Well Construction Permit#: aclo '• ,;t- 3 a O FROM TO DIAMETER TMCENESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) R• fL in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: FR M �O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public 0 a. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g• g• in.
Industrial/Commercial Residential Water Supply(shared) 10-GROUT
_ hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ..
Non-Water Supply Well: a ft. IqC) ft. 3 9, t'_ POt re-,1 + RyArale-
:Jmonitoring I Recovery n• fL Ce !6
Injection Well:
ft. ft.
Aquifer Recharge [(Groundwater Remediation
19.SAND/GRAVEL.PACK Ka livable s
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets•if n
Geothermal(Heatin Cooling-Retum) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Larches,solFrvck type,grain dzp,eta)
ft. ft. Ve
4.Date Well(s)Completed:(n"oZ�n'oSoZ Well ID# 7 ft. 30 ft. • Gj
5a.Well Location: 30 ft. cc) ft. - O
ft: ft.
Facility/Owner Name Facility ID#(if applicable) ft. R• *" r• tom,
Q 1N T-dl1.e LJzk!on 1"c6-CSon MC ft. ft. 1~y,•,r y %.
Physical Address,City,and Zip a7573'7 ft. ft. I r
29 01—9,Q— 30 7 V 21.REMARKS
litter-maaan Prc-coozing Ur+A
County Parcel Identification No.(PII) ` . ULK3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N --29-, 30536 7 W ),,(" � � & -2&"2Z
6.Is(are)the well(s)OPermanent or OTemporary of Certified Well Con or Date
4 signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O1 Yes or Moo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on.the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a-For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dif feretu(example-3@200'and 2Qa 100D construction to the following.
10.Static water level below top of casing: oZ A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: i (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n + - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,` 4 0.0 t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: pp 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 9(-,) Method of test:91ot'an '20 t►i, 24c-For Water SuDDIv&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: 1kT 14 Amount: � d2 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 Resources Revised 2-22-2016