GW1-2022-07997_Well Construction - GW1_20220830

WELL CONSTRUCTION-RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wefl Contractor Information: _
!� / /{ (/I 1 14.WATER ZONES
/J e-[ ( / ,(� �'�7)/ /f [/�.�� FROM TO DESCRIPTION
Well Contractor Name.. s /7 ft. ft.
6!1 _/O
a0-3 ft. ft•
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR'LINER(if applicable)
j ly FROM TO DIAMETER THICKNESS MATERIAL
Company Name .101 :46.INNER CAST G OR TUBING' eothermal closed-loop)..
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#:s��a a . 52 ft. ft. in.
List all applicable[yell constziction permits(i.e.County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
o
❑Agricultural ❑Municipal/Public ft. ft. in.
Supply) esr Supply(single) ft ft. in.
❑Geothermal(Heating/CoolingSu 1 �ential Water 5u t sin le
❑industrial/Commercial ❑Residential Water Supply(shared) .18:GROUT:
FROM TO JHATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irfi ation ft. © ft- 4
ft. ft. =i
Non-Water Supply Well: h"�At11--
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL:PACK(if a ticable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMEN METHOD
ft rr.
❑Aquifer Test ❑Stormwater Drainage
tt ft
❑Experimental Technology El Subsidence Control
20:DRILLING tiOG attach additional sheets ifnecessa "
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color•hardness,soiVrock type.gmin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 40 ft ft. E' i7
G �1 ft. Ct
4.Date Well(s)Completed: tT 02 ! 2 S a C
fL ft. �r � CLte�i
55 We I Location -1 ASfL �O fL r
' ft ft t
Facility/Owner Name Facility ID#(if applicable) ft ft
/f T©.5� �a' h C 7 ft. ft AU6 3 Q 2022
Physical Address,(City,and Zip ,I
Q l J 1-1�a� �� 21.REMARKS
County Parcel Identification No_(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wwellfiield,one lattlong is sufficient)
.il�
a. _7, C70 ci! N CqQ i 236,5 ie1.
a �� Signature of Certified Well Contractor Dale
6.Is(are)the well(s): rmanent Or ❑Temporary By signing this form,I hereby certfv that the ivell(s)ivas(ivere)constructed in accordance
with 15A NCAC 02C:0100 or 15A VCAC'02C.0200 iI'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 214 copy ofthis record has beet,provided to the well owner.
If this is a repair,fill out drown well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple hyection or non-water supply meBs ONLY with the same construction,you can
submit one form. ^� 24.Submittal Instructions:
9.Total-well depth below land surface: J � ® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
e 10.Static water level below top of casing: 3 (ft-) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /I (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: !1(9 Y—Cr f/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4-1 0 Method of test: 19 / 24c.For Water SuuDiv&Geothermal 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: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013