GW1-2022-07458_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /- d
�Ir f✓) tuet r(% SLGcIC 0,I,,tl�t '14.UNIWATERZONES
FR TO DESCRIPTIO� N
Well Contra Name rr ft. ft. /r.�
33 �C7/clor
14- ft. ft.
i
NC Well Contraclor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
/'//j vy I FROM TO DIA\1ETF,R TnICKNP;SS aIAT@:RIAI.
/ ft. ft, in.
Company`lame 16.INNER CASING OR TUBING eothermal closed-IGo
f� r FROM 10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:1 e? L 14 1 yl! J
List all applicableor•1/e-r,nso wlinnpernut.c 0.o U/C.Lome/r.. u/ Va'i cr.etc,) ❑. ft. in.
3.Well lase(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft, in.
Geothermal(Ileating,Cooling Supply) [IResidential Wafer Supply(single) ft. I ft. in.
Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO N1A11 FIR IA1. I1NM4rEWThWATHffD OGNT
Von-Water Suppy Well: ft. ft.
Monitoring ['Recovery ft. H.
Injection Well: ft. ft. ram.
"P'F('i�tAc•;1 f f:`'i.Fu�45�Z��1l
Aquifer Recharge [Groundwater Reinediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [ISalinity Barrier FROM To MATERIAL EMPLACF.NIF.NT ME1'1101)
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technolog}° [ISubsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
RFROM TO DESCRIPTION(color,hardness,sof/rack tt e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under±121 Remarks) G ft. i7 ,
4.Date Well(s)Completed: "/c_ Z Nell ID#�/'7'� 6 ft.
5a.Well Location: J� _ % c .'/ ( i-Cl-2\ i':3I,olw(V'OC�:,,
ft. t't.
Facilily/O„nci Name Facility ID±7 lit applicable) ft. ft.
Physical Address,City.and Zip J ft. ft. -- -----J
b awl// , -S 21.REMARKS () //�� j }III
County !/` Parcel Idenlification No.(PIN) /'" � '1 Cn/V�Qc�)wv'e C. k/lA(
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r' ^' /�"~� t e:�i' "�' r-r'�"'�) 0i4c, h/, _
0f,eell Field.one lavlungg its sufficient) p• 22.CertifC\JfiO�n CU mLr' CA-G(�. /.t/[in•'v7L'/i/i.c.'JJ C9�+1et GtiI ��ll'
6.Is(are)the well(s)oPermanent or W'remporary Signature of Certified Well Contractor Date a
81;signing dri•,finvn. I herehl, that the•nrlll>1 uvta(1,'ercl c'un timied in accardame
7.Is this a repair to an existing well [l'es or NNo with 15.4 A'CIC 02C.0100 or ISA NCAC 02C.0200 Well C'nnsi,action Simiduril,,and lhat u
Ifthis is I repair.fill ow krror­reel/ronsn if,riun infcn t„mw)and��.;pi Im the nano e o/1hP rope of this record has hcen pi orirledta the well owner.
repair uncle, 4'1,eniw k.,section o,un di('hack a%this/urn:.
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 ,tell site details or well
construction,only I (AV I is needed. Indicate TOTAL NtiPvlBf'.R of wells construction details. You may also attach additional pages if necessary.
drilled: ''
-- - ------ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S � (ft.) 24a. For All Wells: Submit flits form ttithin 30 days of completion of•.tell
For multiple moll.,lisl a/I depll's if-.li/lm,al/crmnp/e i i6200�aryl-'tit,/Q(,"1 construction l0 the following:
10.Static water level below top of casing: 6 •. (ft.) Division of Water Resources,Information Processing Unit,
//'ucuer ler•el is abmc ra,m,4,a,e ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: In addition to sending the fonn to the address in 24a
above, also submit one copy of(this form within 30 days of completion of well
12.Well construction method: 0 'V/ L
--- construction to the following: j
(i.c.auger.rotary,cable.direct push,etc.I
-_- -_�.-_- Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Nlethod of test: 24c. For Water Supply& Ini Iction Wells: In addition to sending the form to
the address(es) above- also submit one copy of this form within 30 days of
131).Disinfection type: Amount: completion of well construction to the county health department of the co lint y
where constructed.
Form GW-I Norh Carolina Department of Em imnnnonlal Quality-Division of Water Resources Re,iscd 2-'_2 L10;6
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