GW1-2022-07885_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
& "w R, A 9_)1�non 14. ATER ZONES
Well Contractor Name FR M TO DESCRIPTION
tAmc
NC Well Contractor Certification Number
' ` 15. UTER CASING(for multi-cased wells)OR LINER(if a licable)
1 [� 1 G/� ° � .�n� FROM TO DIAMETER THICKNESS MATERIAL
IIIJJJ�VVJ Nam C. ". ft. m. "_�
Company Name �J X
16.INNER CASING OR TUBING(geothermal ciosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17. CREEN
FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public
Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in.
Industrial/CommercialID Residential Water Supply(shared) 18.GROUT
—Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Ono I ft.. ZffQ r
Monitoring �Recovely g, ft. t 1
Injection Well:
ft. tt.
Aquifer Recharge OGroundwater Remediation
19. AND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stor iwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessar )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO To DESCRIPTION(color,hardness,soiUrock e, rain size,etc.]
c� ft. f tt. d CJ40
4.Date Well(s)Completed: O�[—�O—pl®� Well ID# I ft. r ft.
5a.Well Location: l Ft. Vd�ft. Q
M i C. R bL4 ft. ft.
FacilityiOwner Name Facility ID#(if applicable)
No CD
tt. ft.
Physical Address,City,and Zip
C.�)t)iz.6KQ e 21. EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .C(rtifieation:
N W e
6.Is(are)the well(sPermanent or Temporary Si nat re of Certified Well Contractor Date
By sig ing this farm, I hereby certr&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes orAneplain
o wi Jr,1 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information the nature ofthe c py o this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You relay 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: ( 1 (ft-) 24a. tor All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d�fterent(example,-(3 t`t 200'and 2 a 100') construction to the following:
10.Static water level below to of easing: '1'(�l
p g• (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level it above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( 2 _(in.) 24b.gor Iniection Wells: In addition to sending the form to the address in 24a
above,;also submit one copy of this form within 30 days of completion of well
12.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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C) Method of test:A I IZ 24c.Fpr Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Pt, Amount: C_';b completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016