GW1-2022-07462_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
�1.Well Contractor Information:
C' 14.WATER ZONES l
O
Well Contractor Name FROM T DESCRIPTION
(� G- 1, l�.' 1 r'.✓c /� < /c'
O -71 14
�.-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
/t J ��'' FROM TO DIAMETER' THICKN F.SS h1ATER1AL
Company Name
n 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ��?r 1,34 /1 4z2, FROM TO I DIAMETER THICKNESS MATERIAI.
List till applicable well c•onsUvc•tion permits(i.e.U1C.Coan(r,State, lariance.etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
Agricultural al/Public ft. ft. id
Geothermal(Heatin Sup y it i tial Water Supply(single) ft. ft. in.
IndustriaUCommercial �1��p(��sidential Water Supply(shared) 18,GROUT
lrrl ation Ali`� �', 'J FROM TO MATERIAL EMPLACF,MF,NT METHOD&AMOUNT
Non-Water Supply Well: urth
Monitoring {ytGi91 L1 Pr; Recovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,ere. �J
/ ft. /,'�-� �o ' 2.' K.
4.Date Well(s)Completed: 7/ 3 -2 -"'ell ID#.�-`;) Z fL -.3 C� tr. 5�y 42 _ / /
5a.Well Location:: �( / �0 rt. 3 ,V,'
(- 1't. .1e t'i` ��-"-✓'G{M+ fC
Facility/Owner Name )� Facility Jl D#(ifapplicable) ft. ft.
Physical Address,City.and Zip
ft. ft.
21.REMARKS
County Parcel Identification No.iPIN) e> I' L tG (/O(r 1 k)yN'Q e,, Gt Aloe. `Y rr�F��t''
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tti a".J L.�ti �'''L& �I vA Y ern'E_". �i a';n��ti�'wr, [. fuel
(ifwell field,one lat/lung is sufficient) / ' f /V L,L„/ 1
22/Cert�ificatigq: Jet 7�u� .:1+!Coll,u
6.Is(are)the well(s)oPermanent or OTemporary Signature o(Cenified Well Contractor Date
1iv signing Htic Junin.1 herehr cerGli•that the well(-)was(were)eonstruc•ted in accordance
7.Is this a repair to an existing well: DYes or [MNo with 15.4 NCAC 02C.01e0 or 15A NCAC 01C.n200 Well Consrrucrion Standm-tls and that a
/l this is a repair.ill out known well construction information and explain the natm e o.1 the copy of this record has heen provided io the well owner.
repair under 421 remarks section or on the hack Ql thisJawm.
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-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: Li (ft-) 249. For All Wells: Submit this form within 30 days of completion of well
For tnu/tiple wells list all depncs i/diJjerAt(ecotple-3Lu200'and 2r, /00,) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
l/water level is above easing.ucc"+"/ 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: G��✓! t- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply& IniecIlion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection ty,pe: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Di+ision of Water Resources Revised 2-22-2016