GW1-2022-08029_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,�•�,v,"•
1.Well Contractor Information:
1 y1`j e t\. L( 14.WATER ZONES
Well Contractol Name FROM TO DFSCRICI'ION
,s5ql it. ft-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a liable
FROthI TO DIAMEl'$R TIIICKNESS MikTERML
k�g- 51 e. A l apt l� n�. ft. 3xI. 6 t q in. p 1 D
Company Name
16.INNER CASINGORTUBING(geothermal closed-loo )
2.Well Construction Permit#: 0 FROM To DIAMETER THICKNESS . MATERIAL
List all applicable it-ell construction permits(Le.U1C,Counh.State,Variance,etc..) H. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAIIHEI'ER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 I_ ft. in.
Geothermal(I-leating/Cooling Supply) NResidential Water Supply(single) ft. ft. in.
Phhdustrial/Commercial Residential Water Supply(shared)
1&GROUT
IIriaation FROM TO MATERLIL EAMIACEMENT METHOD&AMOUNr
Non-Water Supply Well: L.
(� it. n. P t
Monitoring Recovery I.
Injection Well:
n. n.
Aquifer Recharge [3Grotmdwater Remediation
19.SANDlGRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERLIL EMPLACEMENT METHOD
OAquifer Test ❑IStormwaterDrainage ft. it
®Experimental Technology Subsidence Control ft. ft.
OGeothemial(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(I3eating/Cooling Return) Other(explain under iF21 Remarks) FROM TO DESCRIPTION(color,hardness,so0/rock type,grain size,etc.)
ft. ft. r, 50 /
4.Date'*'Vcll(s)Completed: � X /V wt
22-Well ID# ��0 n' 19 30 ft lr 1 o n .5e .% e t'L C(t^ -K 0 '
Sa.Well Location: ft. H
1 bs . 01,
I YYI0T-f'IU ft. ft
Facility/OnmerN me Facility ID0(if applicable) R. ft.
ft. It. - ='9
I D 1 LO ,Vv�'t c ner-c 1�tne p n i)p� 11
Physical Address;City,and Zip ft. M
y Q-a 21.REMARKS AUG
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
-3� 3 N _ 3at� �! tivI 7.0. �-
6.Is(are)the wells)JIPermanent or ❑ITemporan Signature ofdcrtificdWqfi Contractor Date
By signing this form,1 hereb}•certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EgNo trith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knoam well construction information and explain the nature ofthe copy afthis record has been provided to the well owner.
repair tinder r21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobc/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:_ , SUBI4IITCAL INSTRUCTIONS
9.Total well depth below land surface: S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 u200'wtd 2 tr100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (P (in.) 24b.For Injection 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: f7 t C �-�` I
(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: [� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) D Method of test: 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: f Amount 7 p - completion of well construction to the county health department of the county
01 where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016