GW1-2022-08392_Well Construction - GW1_20220829

��re,r-i vtur
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CnS Ci n l�'Q.✓� !'1� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft- Cr nn
NC Well Contractor Certification Number ` ft. fL
J_V t l'R_TI.2 I&OdRCAS MforDIAN[LTER THICKNES`S ATI RIALFOM TO
ft. in.
Company Name
P Y 01
16.INNER CASING ORTUBING eothermal closed400
2.Well Construction Permit#: FROM TO DIAMErER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. U•
3.Well Use(check well use): ft' f t' in.
Water Supply Well: '17.SCREEN.
Pp y FROM TO DLAETiER SLOT SIZE THICKNESS MATERIAL
Agricultural E)M cipal/Public 0 f- ft. iI�•
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
I_:Industrial/Commercial DResidential Water Supply(shared) I&GROUT.,
Irri anon - FROM TO MATERAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL -7 ft' P.
Monitoring DRecovery ft. ft.
Injection ell:
ft. ft.AquiferRW echarge ;; GroundwaterRemediation _.
19.SAND/GRAVEL PACK f r.a llcable
E. Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage ft. ft.
I Experimental Technology OSubsidence Control ft ft. i
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets
FROM TO DESCRIPTION(color,hardness,soiVtmk e, n dze,etc.)
Geothermal(lleating/Coolin Return) - Other(explain under#21 Remarks ft. ft.
4.Date Well(s)Completed.9-
-Well EN ft. ft.
5a.Well Location: ft. ft. G
ft. ft. a„ b n _.,L.,'
Facili�//v((nerName l )^I1s�1 a 1Faciiliitty D4(ifapplicab`l_e),, ,• ft. ft. A J(, 2 9 2022
s-GG st�rI iv tI t y o►1 C�VV +M�Mr9I�W1 Z fr. fr.
Physical Address,City,and Zip a `fir 3
21.`REMARKS Counly Parcel Identification No.(PIN) r" t I` U.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifrwell field,one latllong is sufficient) 22.Certification:
r J / rl N 79�33 3� 130�/ 1 W •� �
6.Is(are)the well(s)�P rmanent or OTemporary SignatuigofCertified Well Contractor Date
By signing this form,I hereby cer*that t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: bY. or ON. 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 retnarls section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprohe/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 ifnecessary_
drilled: SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: l 6(�v -(ft) 24a•For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (% U
above, also submit one copy of this farm within 30 days of completion of well
�Y construction to the following:
(i.e. ty,e.sugar,rota cable,direct push,etc.)
Division of WaterResonrees,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 'l Method of test y^�• 24c.For Water SnDniy&Injection Wells: In addition to sending the form to
1 -7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I`c Amount / Gt7 S 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