GW1-2022-07710_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. IW-elll Contractor Information:
►1 1`j D " P�l SI e1� 14.WATER ZONES I
Well Conti for Name FROM TO DESCREMON
`JS L�1 I p?j 1► S� n. 'j! I
NC Well Contractor Certification Number R SIRS " � Yy\
15.OU77ER CASING for multi-cased wells OR LINER !rap liable
FROM TO DL-AE R THICKNESS MATT R�sl eta s I��r t 11�mac, l n�. in. ,07,►0 QV C,
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �j i S 44 FROMTo DIAMETER THICI6VFSs MATERIAL
List all applicable well constnuction permits fte.WC,County,State,Variance,etc.) h- H- in.
3.Well Use(check well use): n' n' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Mtmicipab?ublic U ft. M in.
Geothermal(Heating/Cooling Supply) f@Residential Water Supply(single) B. M in,
Industrial/Commercial Residential Water Supply(sham)
1&GROUP �
hTi ation FROM I TO AATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: V H' H' CQ)(n UV A
Monitoring DRecovery ft. B. 1
Injection Well:
R. H.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ita liable
Aquifer Storage and Recovery Salinity Barrier FROM TO h1ATERIAI, EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 8. ft.
Experimental Technology QSubsidence Control rt. it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DFSCRIPTION color,bareness,soillrock type,grain sae,etc.)
B. B. TIT 501 1
4.Date Well(s)Completed: Well ID# 3-3t S 44
1 n ct' 1
Sa.Well Location: ft. o R 459
i
ft. ft..
�_ �vid�- Skzahhc.r�.el'la
Facility/Owner Name Facility IDS(if applicable) B• H•
6 2?, Cnor%-", Q x- 7yrQ , Ate- 9-70S RECEIVED
n a.
Physical Address,City,and Zip o I 11 ft' H
`rr�y i I I e_ 9 0 u.REMARKS 3
County Parcel Identification No.(PIN)
r rY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2212TOG
(if well field,one ladlong is sufficient) 22.Certification:
15 331 N -7 3 W 4J,4 f� . 04 ;Lo -
6.Is(are)the well(s)iAPermanegt or ❑ITemporary Signature of C tified Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)consintcled in accordance
7.is this a repair to an existing wew- E)Yes or fa Nowith 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill out known well construction information and explain the nature ofthe cope of this record has been provided to the well owner.
repair tinder 921 remarks section or on the back of this 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-D S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For ntnitiple wells list all depths ifd different(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �}I� KO -1Z� construction to the following: i
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,�Undcrground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ( Method of test: 1t 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit''one copy of this font within 30 days of
13b.Disinfection type: Amount: 4)7-- completion of well construction to,the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016