GW1-2022-07899_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) r
Internal Use Only:
1.Well Contractor Information:
�,bw , \ 14.WATER ZONES
Well Contractor Name FRO I TO DESCRIPTION
Ray�+`r
y 1✓
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Z 1 �^ —�•�_C FRO TO DIAMETER THICKNESS MATERIAL
t t ._LY 1 ft. rt. <'1 L-in.
Company Name O'l7
16.11 NER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FRO [ I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction perunits(i.e.U1C,Canty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.s REENFROP TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) `5kesidential Water Supply(single) ft. ft. in,
industrial/Commercial `[3Residential Water Supply(shared) 18.Q I tOUT
Irri ation FRO TO MATERIAL EMPLACEMENTMETHOD&AMOLINT
Non-Water Supply Well:
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.S NDlGRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FRO TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater•Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Traccr 20. ILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO TO DESCRIPTION(color,hardness,sniUreck t c,grain size,etc.)
ft. t I.
CLAW
4.Date Well(s)Completed:s— 1 Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
yt tot) tot t it 1 e . RCS 2$9L
PhysicalAddress,City, ft. ft.
21.11I-MARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) 22.Cortifieation:
N W U � -'-Q—022
6.Is(are)the well(s) Permanent or ®ITemporary ig at re of Cenitied well Contractor ate
5�,r By.igoing this Jornu.i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or (;K1No ! Wit r 0A NC..1C 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If)his is a reltaii,,fill nut known well construction information inNerplain the nature of the� col (?l this trcotd has been provided to the Hell owner.
repair under#21 remarks section or o))the back o/'this farm. `-"23.Sike diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You Dlay 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 constiNction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: D _(ft.) 24a. tor All Wells: Submit this form within 30 days of completion of well
Fm•multiple wells list all depths if different(esanp e-30,200'a»d 2@100') consti[oction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.)or Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 R
abovoi also submit one copy of this form within 30 days of completion of well
consu!Mellon to the following:
(i.e.auger,rotary,cable,direct push,etc.)
DOision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 15 — Method of test:Y-tl 24c. or Water Suggly&Iniection Wells: h)addition to sending the form to
7 the ii dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: P �I`` Amount: 30 completion of well construction to the county health department of the county
wher4i constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016