GW1-2022-08265_Well Construction - GW1_20220505

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.W Contractor formation:
)c,
nc
14<WATSR ZONES
Well ContractorN FROM TO DESCRtP770
.1. ft.
Wei Contnator, ficatianNumlier r is,"OUTER CASING far;IDnlit fasetl;iveil`s=OR:Ist1lER fe""°iliable
FROM TO DU111ETE12 Tfl1 a RIAL
Company Name i Q R '
nl 1 C i y _ 76:1NNER CASfNG ORa.TLTBMG eothefmat eloied-too
L Well Construction Permit#: Lr (`J Z FROM TO D1AMLTER THICKNESS I MATeweL
Uri all applicable well construction permits(l.e.UIC,&unoy State Variance,eta) ft ft in
3.Well Use(check well use): n. M In.
Water Supply Wen: '17:'SCREEN
FROM TO ..^ DIAMETER SLOTSUE THXKNFM MATERIAL
OAgricaltuml O1NunicipaYPublic O in. Q
[3Geothet7nai(Heating/Cooling Supply) OResidentiai Water Supply(single) ft tL ►a
t]IDdustriai/Commercial OResidential Water Supply.(shared)
�18,GROlM.
_ .tion __..__.. ❑Wells>Io0,000GPD..._ FROM I To MATER1At. FA PIACFAUMff MEWOD tY AMOUNT I_ -
Non-Water Supply Well:
ft. ft.
❑ivionitoring ❑Recovery ft. R. +
Injection Well:
R. ft
OAquifer Recharge ❑Groundwater Remediation
49.SAND/GRAY$L'PXCK:° :i 'licable.°,.
- ❑Aquifer Storage and.Recovery OSalinity Barrier FROM TO MATERIAL rArP1,A OD
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
OGeothertnal(Closed Loop) OTracer 20:DAILLING;I OG oftieii iidditionil(etiFeia"ifn`Fe'" "
OGeothemial(Heating/Coolin Return) OOther( " lain under#21 Remarks), FROM TO DFS PI'1 CRION color,hardam solirrock. . sire etc
ft ft :i-
4..Data Weli(s)Completed. z 7 Weil 1D# t
Ss.Well Location:
T?, s e
FacilityKNmer Name Facility IDe(if applicable) n• ft
PhysicalAddn:*,City,and Zip
J.
J `�1 O M.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22,Ce IIIcation:
6.fs(are)the well(s) APermanent or . ❑'Temporary Eimturcof s<rr all f cm! Dau
BY signing uform,thereby eeriffy that the wells)was(nrrel construded in accordance with
7.Is this a,repair to an ezisdng well: OYes or ANo 134 NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a copy
#ihis is a rrpdr,fill out knonm xWll construction information and explain the natum ofthe of this record has been provided to the cull otmer.
repair under#21 remash section or an the back of lhisform. 23_Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional'well construction info'
construction,only OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box4.You may also attach additional pages if necessary.
drilled: / 24.SUBMMAL INSTRUCTIONS;
9.Total well depth below land surface. � � (fi)
For mu le iefis'l ltipylai ale deptl+s i(dj)Tirent(ezpmpio 3(s200 and 2�100 J Submit thisGW-1 within 30 days of I ell completion per the following:
10.Static water levei'b4t,"top of casing: 1 �? (fL) 24a.For Ali Weller Original'foffn,io';Division of Water Resources (DWR),
11%,aaer.7eve1Is above cosing,use Hr,» Information Processing Unit,161.7 MSC,Raleigh,NC 27699-1611
11.Borehole diameter. (in.) 14b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
_( Program 1636 MSC,Raleigh,NC 27609-1636
12.Weti construction method: "( ✓V 24c.For Water Su I "and O ea-Lao 'Geothermal Return Wcils:Copy the,
(i e.auger,rotary,cable direct push ac.) couni7-mvironmental licaliIii depitriment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells pr6duchik over 100,000 GPD:Copy to DWI&CCPCUA.
' PeroSit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gprn) f� Method of test:
13b,Disinfection type: Amo ft't
Form O W4 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6.2018