GW1-2022-08626_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name !I FROM TO DESCRIPTION p
C] ft. 7^(� 5 1 f
ft. a1 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICK`NESS MATERIAL
+, ft. b ft. Q in. Sohq© 1 I VG
Company Name
, ^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: VAU ` FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8 UI. ft. a in. O1a S _�D PV(-
t� t 1'1
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑/Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. .cv-i-f�,
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage O ft. q D.ft. -w-o
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color],hardness,soil/rock type,grain size,etc.)
ft. ^ ft.
4.Date Well(s)Completed: Well ID# aft. L� ft. Dl h &ICA.It
5a.Well Location: ft. ft. n G a
ass a Vft. g ft. t�e ,,� GCa
Facility/Owner Name Facility I'/D�+#(iif�applicable) 46 ft. b ft. t e C 1 ex
�
�q 1��hh Saa �d► \,�GIY�-fin, `�' 2
d ft. ft. r,
PI" "cal Address,City,and Zip
ft.
��\t 21.REMARKS `
County v` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lar/long is sufficient) t _[ r 22.Certification: tra Irk
J�1 1 LAD Q5-( I N I� "L04CI W ' e
��IiLsa L✓ � -�12 3
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certi d Well ContractDate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2 10 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information arid explain the nature of the 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 we➢1 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Cl D (ft.)
For multiple wells list all depths if different(example-30200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
' '
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ukA 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:TT
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
�I
1 '13b.Disinfection type: Ul Amount: 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I '