GW1-2022-07233_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.. il Contractor Information:
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c FROM TO DESCRIPTION
Well Contractor Name
ft. .7
ft. dVl
ft. / %
NC Well Contractor Certification Number 1'S."OUTER CASIIYG for multi=case l wells" R LINER" a' llcable
FROM TO DIAMETER O4TfIInCKnNES�3/ MATERIAL
ft. v ft. IV
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Company Name ''•16,:INNERCASINGORTUBING eothermat'closed-►ooi _.
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i e.VIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. tt. + in.
FWaterpply Well: A7 SCREEN.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tural OMu cipal/Public G ft. ft. in-
mal(Heating/Cooling Supply) ; esidential Water Supply(single) ft. ft. in.
aUCommercial Residential Water Supply(shared) 18rGROUT_n FROM TO MATERIAL E LACEMENTMETHOD& OUNr
Non-Water Supply Well: ft 6 ft.
Monitoring f recovery ft. fL
Injection Well: ft. fL
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK(If applicable)
._
Aquifer Storage and Recovery OSatinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• R•
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20:'DRUJUNG'LOG attachadditional sheets Kn ._
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION color hardn �tvmetc s eta
r ft. ft. cm
4.Date Well(s)Completed: _��J` Well ID# fL fL 16"' "° s
5a.Well Location:
^ �5 ft. ft. AUG
Facility/Owner amre/ �Facility D39(if applicable)
ft• ft. lD�l�" r)k&jc)lm)G
U l L(/q �/11=�� ��/Qi �/'` 1 z 9��` 6 ft. ft.ac
Physical Address,City,and Zip ft. ft.
21.REMARKS.
County Parcel Identification No.(PIN) �Lq1 k,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcllll field,one]aat/AoJng/ids ss}u/ffi/c(iient) Q, 22.Certification: �,�_f� U �+
�U r LOr�( ) I/ N ��y t�.(9 ✓ ( W OL-4 _,gA t1 WZ. � /��L — 6
6.Is(are)the well(s) rmauent or OTemporary Signature of Certified Well Contractor to
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: _ es or t3No with 15A NCAC 02C.0100 or 15A 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 miner.
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 I OW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C�t/ (ft) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2Qa 100) construction to the following:
10.Static water level below bop of casing: qG (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Iniection 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 method: construction to the following:
(i.e.auger,rotary,cable,direct pushy etc.)
Division of Water Resources;Undeiground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: 2,A, 24c.For Water Supply&Ini'echon Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount: o completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division ofWater Resoru+ces Revised 2 22-2016