GW1-2022-07463_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
60 t 1/l6.M 2t M,h Lrl�z� GS Cu1c,
14.WATER ZONES !.
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING for multi-ease'd wells)OR LINER if [!cable)
1 FROM TO DIAMETER THICKNESS aIATERIAI•
(QC �C.(�..�� /✓f'/�r{/G% �•c-- ft. ft. in.
Company Name
pA 16.INNER CASING OR TUBING other at closed-too
2.Well Construction Permit#: Fe V_ 4/� /'C'(/-" FROM TO I DIAMETER THICKNESS -,IATERIAI•
List all applicable well c•onsbvction pernrirs(i.e.U/C.County,State. I%m•imn(e.etc-) L:�±
ft. in.
3.Well Use(check well use): 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) Residential Water Supply(single) ft. I ft. in,
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
/�.�+
h71 at1On s� y FROM TO MATERIAL EMPLACEMENT k1ETHOD&AMOUNT
Non-Water Supply Well: a.e%'.Ja ft. ft.
Monitoring ft. ft.
Injection Well: 3
Aquifer Recharge thub mediation
��-t�_rl 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and RecoNSr Osty,Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control n. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiVrnck type, rain size,etc.
4.Date Well(s)Completed: 7--l L 2 Z-'-Well ID# J7;/)i) R( ccvn•5� r �o:_ , r:i/,
;a.Well Location: // C ft.
or rl�P"io�G..;�l"e°r��� S•o et. �•-s- rt. � •��, - ✓•`,,t�c-t�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3 ti- %g ft. ft.
Physical Address,City.and Zip ft. ft.
�/ 21.REMARKS
County Parcel Identification No.(PIN) `e!h c' ` ��( ! D�DL��O/tt Gtir`l� rg/e is
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: N�Fa✓1LcC` `�-Sc"°' `°� /Vr �" t~e n"� to,, 1, 't27u•7z
(if well field,one lat//lung is sufficient) 22.Certification: /t We'll
' D N Z L W I- .yt 7- 21 -Z L
6.Is(are)the well(s)oPermanent or STemporary Signature of Certified Well ontract(;r' Date
41'signing this/non, l herehv ceridit that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15.4 NC.4C 02C.0100 at-15.4 NCAC 02C.(l200(Fell Construction Standards eau!drat a
/fthls a repair.fill out knrown rteu construction information rn,d e.xprabh the nuuu e ofdhe cope of this record has been provided to the well oth ner.
repair under#21 remarks section or on the back of this fornt.
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: S-� (ft•) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple we/lc list all depths ifdifferent(example-3CJ200'and 2(c.100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
{f water leve/is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
1 �''C'. above,also submit one copy of this form within 30 days of completion of well
Well construction method: 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 lCeinter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply& Injection Wells: In addition to sending(he form to
the address(es) above, also subinii one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction It tothe 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