GW1-2022-07331_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
A 111 11 A n rJ1�C� 14.WATER ZONES 1
WellContrac�Name FROM TO DESCRIPTION
Ho It. aoL)fi- `",
'3 5 4 1 ft. rt.
NC Well Contractor Certification Number
I5.OUTER CASING(for multi-cased webs OR LINER(iCa licablc
11 L ,\ FROM TO DIAMETER TDICKNESS hL1TERLIL
S 'l�z-Q �.�t1�11RG Vl Ci 1 fiB. �[J It tl)ti in. .V�+i10 V �.
Company Name /
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 033 FROM TO DLAA ETER THICKIVFSS MATERLIL
List all applicable well construction permits r.e.WC.County,State,Variance,etc,) ft R. in.
3.Well Use(check well use): 0t. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS M TERLIL
Agricultural DMtmicipaMblic 0 ft. ft. i I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
PIndustrial/Commercial DResidential Water Supply(shared) j
18.GROUT I
Irrigation FROM I TO MATERMI. EWIACEA=MFFHOD&AMOUNT
Non-Water Supply Well: D ft 3LLWjA (C
Monitoring QRecovery 3 ft. a o ft. JJ 'Vl�
Injection Well:
R. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑IAquifer Storage and Recovery Salinity Barrier FROM TO M)kTERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft_ t
QExperimental Technology DSubsidence Control ft. ft.
t3Geothennal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Coolina Return) Other(explain under 1121 Remarks) FRont TO DESCRIPTION(color,hardness soi0rock a grain sae,etc)
Ct. 10 M e I
4.Date Well(s)Completed:,001 'n kcai We11 ID# 1I 3 3 ft. Q ft: 0 I S d 1
Sa.Well Location:
H. ft (�� 111�2 .cam
Faci ity/Owner Name FacilityID4(if applicable) ft B• C
A0 CYOP K IGQse Vlmtt`e5 1�X, �kY�S D�C, fr a
Physical Address,City,and Zip ft. fL AUG
'n ocry,ch ')I.RENJARK.S
VV`vV L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 22.Certification:
36. 3l g% N ��� �<< W - xi a0zL.
6.Is(are)the well(s)OPermanent or ❑ITemporary Signature ofC tified Wel Contractor Date
At,signing this form,I herebv certify that the well(s)it-as(were)constructed in accordance
7.Is this a repair to an emsting well: Dyes or VS No with 15A NCAC 02C.0100 or 15ANC11C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature afthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. i
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 als6 attach additional pages if necessary. -
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D S (Ft-) 24a. For All Wells: Submit thi's form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'mud 2@100) construction to the following:
lU.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service penter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: e- 9-0-t-a-eL� 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: 1636 Mail Service i inter,Raleigh,NC 27699-1636
13a.Yield(gpm) ` lJ Method of test t 24c.For Water Supply&Injection Wells: In addition to sending the form to
� ^ the add-s(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r -Amount: iO completion of well construction to the county health department of the county
where constructed. i
Norm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016