GW1-2022-07760_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j PrlrSt Forth
I.Well Contractor Information:
14.wATERZONEs t :.
Well Contractor Name FROM TO DESCRBrfiON
LO ft Z ft
ft. ft. i
NC Well Contractor Certification Number i
'IS.OUTER CASING for multi cased wells OR LINER ifa ficable
(jyf���C{Qf/ �/� (/�` �I G FROM TO DIAMETER TffiCIQYFSS MATERIAL
Company Name 2 B % i in.
16:,INNER CASING OR TUBING eothermal elrned-foo
2.Well Construction Permit#: 2 Z-QlP►"Oum-&0/ FROM TO DIAlYTFTER THICIWFSg MA—A.
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17.SCREEN FROM I TO IDIAMETER SLOT SIZE THiCKNESg
, ERIAL
Agricultural E)Municipal/Public Q fL MAT
_ Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft.
__;Industriat/Commercial DResidential Water Supply(shared)
18:GROUT
-_t,Geothermal
- lion FROM TO MATERIAL EMPIACE(V ER MbTgOD&AMOUNT
-Water Supply Well: ft, tt
onitoring _Recovery ft.
ction Well:uifer Racier a ft. ft
g E)GroundwaterRemediation
uifer Storage and Recovery E3Salinity Barrier 19.SAND/GRAVEL PACK fo licibleFROMTO MATERIAL EMPLACEMENT METHOD
uifer Test �IStomtwater Drainage 2ftperimental Technology Subsidence Control ft. fr.othermal(ClosedLoop) Tracer 20.DRII;LINc7AG atmchaddiaooatsheetsifneceasa
(Heating/Coolin Return) Other lain under#21 Remarks) FROM To DEscRorrroN color harda soiVeock q la sae etr
V ft. L &
i
4.Date Wells)Completed: 1-Well ID# AAJ Y Z ft. Cs fL r
Sa Well Location: & z sf ft. s ,4
C�ss�-�/ cab ovfec ft. ft
Facility/Owner Na a �• Facility ID#(if applicable) & ft
10� 7 1'&two; 4P ft ft. s -1
Physical Address,City,and Zip ft R A.IJ r
2022
21.REMARKS
County Parcel Identification No.(PIN) Pm—z;,nwM. Unh
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
3� . e�1T93 N _�f• 70�'4�37 W
6.Is(are)the well(s) Permanent or ©ITemporary SiVWOWt:estified well&Jactor Dan
eF
By signing this form,1 hereby certtty that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPTor 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-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS;
9.Total welldepth below lead surface: 2
For mulaple wells list all depths jdlfjerent(example-3@200'and 2®100) ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing,sae
f 2-1Static water fecal below bop of casing: � (ft Division sion of water Resources,Information Processing Unit,
"+�� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_f0. � (iR,) �
M, 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: AV 6 e� above,also submit one copy of this four:within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,ctc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY; Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunniv&Ini I doe Wells: In addition to sending the form to
the addmss(es) above, also submit 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-1 North Carolina Department ofEnvironmental duality-Division of water Resources Revised 2-22-2016
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