GW1-2022-07466_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: l
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�1 iirl / tC"-�� 14.WATER ZONES k
Well Contractor Name FROM TO DESCRIPTION
+w q ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER f a licable
��j��i-n✓ ,� /�J '/OJ'v`'1 �l FROM rt TO ft DIAMF,TF,R in THICKNESS aIATERIAI.
Company Name. !J �i //J 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: /�r �P11 1 4 rD L�C� I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consouctiao permits(i.e. UIC,County,State. Noriance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) H. g, in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supple R'ell: ft. ft.
Monitoring in F_ I V Recovery ft. ft.
Injection Wel:
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Aquifer Recharge' r' J ZM DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage a ecovZ ery linity Barrier FROM TO MATERIAL EiMPLACEM ENT METHOD
Aquifer Te., r yla �f' �` �DStormwater Drainage
Experimental Technolg�"Qi [ISubsidence Control fl. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Dother(explain under#2l Remarks) FROM To DESCRIPTION color,hardness,soil rock h e,grain size,etc.
ft. /O ft. ..V 7...n Jit Ck
.
4.Date Well(s)Completed:/ -P-2 - We111D
5a.Well Location: U ft. 5 H.
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"/t,•N'1 f r``3dl,f�l e, le,A � R• ft.
Facility/Owner Name F Facility ID#(ifapplicable)
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3 G7 SML-. tlt �Lv�/ /
Physical Address,City.and Zip
21.REMARKS �/ l
County e^ Parcel Identification No.(PIN) Lti.'` LUC 61
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Le_-f Lvr. ✓;e, Ai e,-h e. 6-, h 6do_0Q
rw
(if well field,one tat/lung is sufficient) 2pCert'ricatlon: �- V/n / �✓ erg V C' ��p' ��r �• f' 'D
6.Is(are)the well(s)oPermanent or IRTemporary Signature of Certified Well Contractor Dale
By signing this erne, l hereby certifr that the uell(.s/ma.s(werel constructed in etc'c'ordance
7.Is this a repair to an existing well: DYes or ONo with 15.4 A'C.4C 02C.o1nh w' 15.4 NCAC 02C.h2hh we//Con.sovct6m Standard,and that a
Il this i.e.it repair.fill out known we/1 cons fiction information and e.rplain the nature o/the cope of this record has been pi ovider!to the well owner.
repair under 421 remarks section or on the back of this fawn.
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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface. ��� (ft.) 24a. For All Wells: Submit this town within 30 clays of completion of well
For muhiple wells list all depdrs ildiJlment(example-3ca;200'and 2@i 100')
_ construction to the following:
10.Static water level below to of casing. 5'
P g� (ft.) Division of Water Resources,Information Processing Unit,
(!water level is abcme ca.sin,G.use +` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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: -5-0-y/C_ construction to the following:
(i.c.auger,rotary,cable.direct push,etc.)
Division of Water Resources,11-inderground 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& Injection Wells: In addition to sending the form to
the address(es) above, also subtiiit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rcsomccs Revised 2-22-2016