GW1-2022-08197_Well Construction - GW1_20220826

Ill 111 VI111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
�arnt'sdf. b_c�m 14.WATERZONES.
Well Contractor Name FROM TO DESCRII1°17ION
L�o93— PC— rt. 1ZS n' 4t1leiwo
I zs-ft- 320 It. 1 l vL.)
NC Well Contractor Certification Number IS.OCTl'ER CASING(ror multi-cased wells)OR LINER(Ir- Usable) -
FROM TO DLt15FE[ER THUCKNESS MATERLIL
t�J ft. ft. in.
Company Name
l f 16.MER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#: ~ d�4�f FROM TO DIAMETER I THICKNESS MAfTTERIA
List all applicable well construction permits((.e.U1C,County,State,Variance,etc.) b D' 3 It- (P. 2 in. I SD 2 T V C
3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: -
IA_ FROM TO D IRTER SLOT SIZE THICKNESS MATERIAL
AgriculturalM cipal/Public ft. [t. I in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaVCoinmcrcial Residential Water Supply(shared) 1R.GROUT
Itri anon I RO�f TO \fATERtAL ENPI ACE\tE\T MEMOD&AbrOUNT
Non-Water Supply Well: ft. 2-6 fit. t d"K
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation R.
_ 19.SAND/DI GRAVEL PACK a rlttzablc
Aquifer Storage and Recovery DSalinity Barrier FROM TO NUTE6FAL IintPLICERfE\T METHOD
Aquifer Test OStormwaterDrainage R K•
Experimental Technology. DSubsidence Control
BGeothermal(Closed Loop) [3Tmccr 20.DRILLING LOG(attach additimull sheets if necessary)
FROM TO DESCRIPTION(cotar.bardness,sallfrock e, ins"ve.etc.)
Geothermal(Hestia Cooling Rctum) �- Other(explain under#21 Remarks) Q fit. 3 fit. �`a Q U �/„,�
4.Date Wells)Completed: 7�,7' a7 Well ID# 31 tt. Sus— td�-1
5a.Well Location:
ft. tt.
vow &A w h: ft. ft. ��,i��•,: c •_
Facility/Owner Name Facility ID#(if applicable) n' R. ; �.r 44--
N4 Lwo. Cove U_ 4..Lt1a1.�11e�1�L a8787
Physical Address,City,and tip
rr. ft.
pa
nsrs�mbe q14 3 5 Lq$97oo0a� .zLREivcnxxs — v.. +
1k
County Parcel Ideniifiication No.(PIA)
Sb.Latitude and longitude in degreestminutestseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i-S 1.q f,�' N W 29 ' 2. 1 R LI e t W �,
7-a-7- a;k
6.Ware)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify Owl the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: E]Yes or N�, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair.fill out knon7r bell construction infornwtion and erplaht the native of the copy of this record has been provided to the well ouster.
repair under#21 rentarl s section or on the back of this form.
23.Site diagram or additionsl well details:
S.For GeoprobeJDPT 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-I is needed. Indicate TOTAL NUMBER of wells conswction details. You may also attach additional pages if necessary.
drilled: z SURNUTTAL 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 depthr if tli jerenr(example-3@2200'and 2Q100) construction to the following:
10.Static water level below top of casing: '7 (It.) Division of Water Resources,Information Processing Unit,
If eater level is abor•e casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. �' Zg_(in.) 24b.For Iniection 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: a i3a r�:l_ 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:gal. (`.'tYfoL,ClQX. 24c.For Water Supply&Injection 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: 1%1t)ttl•-e Amount: 3 hxbf completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016