GW1-2022-08014_Well Construction - GW1_20220830

7-
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
t
Eric �Arl d ej y'to 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Namc
o ft. 2S rt.
�T?69-A ft. rL
NC Well Contractor Certification Number j 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
�Lir1�QTSut'S W�!, ��1I g FROM ft. TO ft.
to THICKNESS MATERIAL
Company Name V �v LL
309
n 2 Q 16.INNER CASING OR TUBING(geothermal closed-loop)'
2.Well Construction Permit#: �( V— 3 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f Agricultural IM cipaLTublic ft. Z — ft. / in• 1L
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
VAquifer
ter Supply Well: ft. 20 ft.
oring Recovery ft. ft.
n Well:
fL ft.
Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licabler Storage and Recovery E]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fr. ft.
Experimental Technology [DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) `
-I Geothermal
TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ® ft. r 0 fL
4.Date Well(s)Completed: �� ZZ Well ID# ft. Z-0 % C/
5a.Well Location: U ft. Z ft. Sk N cJ er�
Facility/Owner Name Facility ID#(if applicable) tL ft. i.-.., —.. ,�� T„ _•,_,.gc�
Bawl Rd Fi tl /V%od 283 y0 ft. tL t . .:..s`6J 9 ^2•.a
ft. ft. I )
Physicality and Zip //t7rJ L�SCw'1 �b�i 0 l y O 2L REMARKS
/
v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
,one lat/lloong is sufficient) (`fig >� 22.Certification:
6e zy �2
6.Is(are)the well(s) - Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: FlYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knomz ivell construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 26' (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example-3(200'and 2Q100) construction to the following:
10.Static water level below top of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,:use"+" 1 ` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: S% (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /� above, also submit one copy of this form within 30 days of completion of well
"�(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Is— Method of test: � � ��"P 24c.For Water Supply&Injection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: TT Amount: completion of well construction to the county health department of the county