GW1-2022-08303_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Information:
1 11 1 I I P.h S�P M WATER ZONES
FROM TO DFSCR]Fn0N
Well Contractor Name
?15 l n
NC Well Contractor Certification Number 15.OUTER CASING for wed OR LINM rf a ble
,1 ' T TO D TMCENM MA
FR M
Company Nam
n i 16.INNER CASING OR TIEING thermal dosed
2.Well Construction Permit 9: t7 We-1 I FROM TO DEER MHCKNM MATERIAL
List all applicable well construction permits r e.UIC,CoaIIy.State,Varrmrce,etc) D It. in'
3.Well Use(check well use): R• R' in.
f
Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSITE =CENM MATERIAL
cultural0Municipal/Public U fit. tt.hermal(Heah*Cooling Supply) Residential Water Supply(single) tti ftstrial(Commercial Residential water Supply(shared) 18.GROUP
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q tr' ft Ct?��t'v
-. NI Reco j °- a 0 & r1 0 h i
onrtonng �.y__..._.__._..__.__._
Injection Well: ft. R
Aquifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK der cable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT AYMOD
Aquifer Test DStormwater Drainage L R
Experimental Technology Subsidence Control
tl
Geothermal(Closed Loop) [3Tra= 20.DRILLING LOG attach additional sheets ifnecassa
Geothermal(Heating/Cooling Retum) Other(explain under#221 Remarks) FROM 110 DESCRIPTION -)or,lurdacs--rock M*,Varm sac,eta
0 IL }� `t- .04 -I-' re
4.Date Well(s)Completed: I r 4)Xa-Well ,7, "L -l' R p Y ra c:
SR.Well Location:. . 1t 5 I . ft- 6 � � Y i'OG
Facility/Owner Nature Facility W9(if applicable) D• ft. 11
Physical Address.City.and zip ' IL ML MAY 15
2L REMARKS
County Parcel Identification No.(FIl� ltl(OflAttt�IDO f f1�CpmjlZg Vi1�1
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
'�,�• a� boa N `��. �3`�1 Go w 24�1§1QS aoal
6.1s(are)the well(s)oPermanent or DTemporary Signature or r
fied Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JqNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,ftll out brown well construction information and explain the nature ofthe copy ofthis 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 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also,'attach additional pages if necessary.
dried: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a$5- (D•) 24a..For.All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'aul 2@100) construction to the following:
10.Static water level below top of casing: Obi (fk) Division of water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (io.)' ' 24b.For Infection Wells: In addition to sending the form to the address in 24a
�.f)7-14 above, also submit one copy of this form within 30 days of completion of well
12 well construction method: Pr I Q�)
construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mari Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 101, Method of test: i 24c.For Water Supply&Injection Wells- In addition to sending the form to
\\ 6 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:Yl i Amount: n Z— completion of well construction to the county health depaAmmt of the county
where construcletl
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016