GW1-2022-08015_Well Construction - GW1_20220830

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: _T
1.Well Contractor Information:
a
( ! C -JCtirl wPd 5[), 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
U ft. y s ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells OR LINER(it a licable
FROM TO DIAMETER THI�C�K/NESS MATERIAL
SCI.✓1 e�sd�s W �t� ��i�l<<a` � ft. L�U ft. l�� in.
Company Name e7 16.INNER CASING OR TUBING'(geothermal closed-loop) L
2.Well Construction Permit#: Y 0 2- z FROM TO DIAMETER THICKNESS MATERL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. i IA
n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN"
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
! Agricultural vesideeIntaial
pl/Public )tv ft. 11/S ft. y in. Z SL//ya �liL
Geothermal(Heating/Cooling Supply) Water Supply(single) "T ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Iiri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. av fL *ne.-a 6tX�
Monitoring DRecovery ft. ft.
Injection Well:
_ ft. ft.
Aquifer Recharge DGroundwater Remediation
19.'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. f[.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) � ' Other(explain under#21 Remarks)
4.Date Well(s)Completed: 03 �3 2 Z Well ID# )tJ ft- /s ft. 2
5a.Well Location: ft. 3v ft. Chat /a,4- 0,, ->
Lq me% ,D '5kn;f` 30 ft. �av ft I CI&Y c
Facility/Owner Name Facility ID#(if applicable) I(L) ft. ;�t ft- �f f7„/? /- CvalJ el�' sa H✓�
Ty C k2 r Ad, f�.�t 5ro -e 2 F 37 2 ft. 7 ft.
Physical Address,City,and Zip
RAe-so", JyGy 01-00r/7 D3 21.REMARKS
AU6 3 0 ZOR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - _- a r1':'.'•: ;r Lll ;l
(ifwell field,one lat/long is sufficient) 22.Certification
3y" YZ, 554 ' N 91 E %2. 3 // w
6.Is(are)the well(s) rmanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or I o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out buorvrr well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 121 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 I GWA 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: `/6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For•multiple wells list all depths if dierent(example-3 til 00'and 2(a l00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1 it 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: y (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
D_ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: "�"f!: �t{ 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) Method of test f I; � 24c.For 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: NTH Amount: nin 5 completion of well construction to the county health department of the county