GW1-2022-08243_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1./W�ell Contractor Information:
�l I
/ T- Qi �L �J �YV��S �V <14:WATERZONES.:
Well Contractor Nam57 e
/ /� FROM TO DESCRIPTION
L.r b l� 3 ft. 64
ft. `r'1{7
NC Well C`ontractorCertification Number f ' ' Q v�I
e—' T /� (� INC
'IS:Oi1TBR'CiLSIPIG:(lbcmomseawe 'UA"GIIVLK a neable
V" A 1 G R W Z �_ A�I dJ S I��t C �O ft.OM TO O It. DI..I ER in. C 1,4 CKNTL4� MATERIALPVC,
Company Name 16.INNER CASING.OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER I 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.
Water Supply Well: FROM TO DIAMETER SLOT S12E THICKNESS MATERIAL
Agricultural ElMunicipal/Public 0 fL ft. in.
i Geothermal(Heating/Cooling Supply) residential Water Supply(single) R. R. ;n
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q IL 0 D- E .5 Q
Monitoring DRecovery ft. ft.
Irljeetion Well:
ft. fL
"AquIferRecharge oGroundwaterRemediation
19.SAND/GRAVEL PACK(iF a licable
Aquifer Storage and Recovery EISalinityBarrier FROM To I MATERIAL EMPLACEMENTMEMOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft- [
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if m �� �
etc.
i_ Geothermal(Heating/Cooling Return) _' Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness,soiltroeke,grain size,
4.Date Well(s)Completed: — Well ID# A q N —1 ft. ft. ,
5a.Well Location; ft. ft. <,'..�,�D—e...a
a6 A,'SL2C,15 G REC O)21.f ft. ft. I r .2
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
�'
I03 ?I%t&L- pL. 1 inn 8E R G 191 E 4 Ij L
Physical Address,City,and Zip ft. ft.
E i Z 5 CSl� 21.REMARKS
County Parcel Identification No.(PAN) S C t`. CUT 01FE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a R
(ifwell field,one lat/long is sufficient) 22.Certification:
3`t 2ti?d758' N --71, °1 O 79 w /V ram/ 5- 1 ?- Z02
6.Is(are)the well(s) rmanent or OTemp.rary Signature of Certified Well Contractor Date
By signing this form,I hereby cenify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ayes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary_
drilled: SUBMFI TAL INSTRUCTIONS
9.Total well depth below land surface: 1 (I�(S (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 a0200'and 2@100) construction to the following
10.Static water level below bop of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: Q (In) 24b.For Infection Wells: In addition to sending the form to the address in 24a
R aT qt�l-� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.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 27699-16M
13a.Yield m test U lryl Q 24c.For Water Supply&Injection Wells: In addition to sending the form to
e Method of g
(gp ) � S � DD V 1
L� C� the address(es) above, also submit one copy of this form within 30 days of
r7 13b.Disinfection type: -r H Amount: t 0 Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviroumental Quality-Division of Water Resources Revised 2-22-2016