GW1-2022-07460_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J?t,��� l�.r" 14.WATER ZONES
Well Contractor Name FRO�Mj TO DESCRIPTION
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a cable
} s� FROM TO DIAN7 F,TER THICKNESS NIATERIAI.
ceti,Sr d Lrt� rt. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: ���� � r r�33�U ��- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit(i.e. UIC.Coungt State, 141rim,ce.etc.) (t. ft. in.
3.Well Use(check well use): ft. ft. in.
Supply Well: 17.SCREEN
Water Su
PP FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in:i
Industrial/Commercial DResid�RbtaL-WCa-'S I (shared) 18.GROUT
Irrigation ¢ F,Ie— Q ,,i,, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecoveryAi,Jr 1 0 2027 R. ft.
Injection Well: ft. R.
Aquifer RechargeGr�11iPax>ielrtdi�4615.g^tR (J '
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barn''t,yQ/a OG FROM To J MATERIAL EMPI.ACEMF.NT NIFI'tIOD
Aquifer Test DStonmvater Drainage ft. R.
Experimental Technology DSubsidence Control ft. n.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size etc.
�f G rt. �' rt.
4.Date Well(s)Completed:/ �— �- Well I D#,l /.� "' ' �' ft. (' ft. A)�GQ�'4Y)j + G .. `aN
5a.Well Location: f ft. ,O1 w t/ &Y k eLf
ft. G��_
Facility/Owner Name Facility ID#(ifapplicable) /�•- ft'
- e-) ft' }-: L y -•L„'ALN`
Physical Address,City.and Zip ft. ft.
J� vI d�42 /- 2L REMARKS
/County Parcel Identification No.(PIN) '1j e tit + ti �
!N!I/r/4L / 1��„tC'�-- /P-G'Jr`-r,G DI:nG /✓G91 ;�z>J�r!-`u.. ��.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) /',v _! i� �S i� c'►`Z� % �-'eV
22.Certification: C •/°��
3 s'- 6 3—L`f�3 2N -,?e� 2 .31 J W W
6.Is(are)the well(s)OPermanenI or itTemporary Signature of Cerlitied Well Contractor Date
Br signing this frn'nt/herehr verb&that the,ve/hs)was(were)c•onswitcted in accordance
7.Is this a repair to an existing well: Dyes or [@No pith 15A NCAC 01C.0100 or 15,4 NCAC 02C.0200 well Con.srntclion Srandards and that a
1f this is a repair,fill out knoun,tell construction inhortnaiion and m ploin the nano-e tithe ropy of this record has been provided to the,tell o,rner.
repair under#21 renim-L section or on the back ofthis 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 GW-I 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: CC -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if din�rent(ermnple-3C(W00'and 2r,t 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If crater level is above casing.rise'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the fonm to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �r��`1f% 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 Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply& Infection 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: Amount: completion of well construction ko the county health department of the county
where constructed.
For GW-I North Carolina Department of Environmental Quality-Dix ision of Water Resources Revised 2-22-2016