GW1-2022-09115_Well Construction - GW1_20220926

WELL, CONST'RUC'TION RECORD (GW-1) For Internal Use Oniv:
I.Well Contractor Information: S
�� �d i�• 14.WATER ZONES )
Well Contractor Name FROM TO DESCRIPTION
to ft.tt. <Is
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LI ER(if a licable
FROM TO DIA4tETER Tili 1,ET
MATERIAL
£t. ft. j in. -
Company Name
�rO(O�0 16.INNER CASING OR TUBING(geotherrtal closrd-loop:
2.Well Construction Permit#: t,� FROM? TO DLAMETER THICKNESS i MATERIAL
List all applicable❑•ell construction permits(i.e. WC.Count'.Srate. I4n-iance.erc•.) & in. ! S n a
3.Well Use(check well use): ft. ��•/✓it. `(� in. P'1
Water Supply Well: 17.SCREEN
PROM TO Dl.�t)tETER SLt5rS1LE Tlitc_A.`CfiS MATERIAL
Agi icultural Municipal/Public
Gco.hoinal(Hcatine/Cooling Supply), ORcsidential Water Supply(single) ft. ft. in. t ��
1 Industrial(onnnerciai DResidentiai Water Supply(shared) 18.GROUT
I 'Irrieadon FROM TO �?ATERIAL i EJIPLACEI1ENr'.IETIIOD&AMOUNT
\on-W:tter'+iePPlyR'ell: D fL i a5S:t. '1he^Vex. i fr`•01 e- /,;P.t L —I Moniwring MRecovcry i ft. i p
injection Well: t d
fL ff.
Aquder Recharge Groundwater Remediation ! i Pe_ w e—
1
�-•� f m' 1 ND/GRAVEL P:'. •.(if applicable)
Aquifer Storage and Recovery DSaliniry Barrie F�CA a IV,
� �,,y„p 0\. TO _M_.vTERIAL E11I'!.�C"NENT:IIETHOD
:JiAqu; Test [IStorrrwater Drainage Iw ` " ft. t. -
E imental Technology OSubsidenceContrS.F P El 20 It. Ci. I —
I :Geoiliernia!tClosedLoop) O'.Tracer s _ Z0.DR1I_LINGLOG(attech n1ditionalsheets ill
nec:ssan)
Iflrut•r�'B.;S�:1 "i C' ^K; i TO
te, n size,etc.)
D�SCR.tPTIO\ico(oc i:u dress. ,:I'rncl: grain
DGeothenna!(heating/Cooling Return) Other(explain under9# fl&,r p?ks) , D fr.
I
4.Date Well(s)Completed: 2 Well ID# ft. i.. G!�►� Md S
ft. 7 rt.
Sa.V1 ell Location: j'D
F:cilIt
i;}t,,r:: \;:me Faci:iryi.D=(ifappiicablc) _Lv ft.
!2:0'`�11_ A,
Physic;a A1,ddres;..City,and Zip � ---
ur�^� 21.REMARKS ----
C'ouni,: t Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ I
(ir,vcli ii,�ld.orc:atllong i..sufficient) 22.Certification:
6,Is(arei tlu•wells)O3 Permanent or CITemporary Signature of Ccrtitied We:i'C7mr4c'My 'kac
At.signing this/in-m.!iier.h ;_,•r jr thus the ,rifr..r r,,r. (we..r ,,+:.tnxied in accordance
7.Is this a repuir to an existing well: Yes or �o wiih 15A VC.:C 02C.0/r ,;r 1>::.h'C'•4C 4°C.i:'00 If'...Cot,. -a:.-i Smndardr and that a
rrpa:r,fill nut known arll constrliction information and explain the nawre gfthe oRi'4ftlu re--or•d has ter,,1'al;:iL'd the ire!!. „ne•r.
it-pair m:«er as;remurks section or tun the hack of this faun.
23.Site diagram or additional well details:
S.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back or thi;pare to pro,ide ac.dition:�. % e: site details or well
constrii tior-.olds Get`-1 is heeded. Indic:to TOTAL NI MBER.of wells construction details. Y,. a'so ant c+i:..udi:iol-ai par:;i:'.: ccssary.
SUBMITTAL I\STRLI IIONS —
9.Total w'eL death below land surface: 6 3 -2- S (ft.) 24a. For All Wells:
c ih-s form .ithin 30 dais o' :um letion of well
Far umlrp!e tri•:rs list all depths if dilferent!e.ranipie-3rdi200'and 2(a"100') construction to the follu,t'iaa� P
10.Static water level below top of casing: Il 0 (ft.) Division of Watei•Rest>urces.Infornu:tion Proc•:king Unit,
p:raMr!ewl is a1,n,c ewi+rg.use.•+" 1617 Mai:Sri vice Center,Raleigla.\C?7099-1617
11.Borehole diameter: (in.) 24b. For lniection ik tPs: addimn to cendir,.c the):n:.:.:tie address in 24a
t J above. also submit one cvo-, of :his term within: 30 &,'s o. completion of well
12.Well construction method: construction to the foliwtinq:
(i.e.auger.roury.cable•direct push.etc.)
FOR WATER SUPPLY WTI LS ONLY: Division of Water Res urces,Underground Injection C:,ntrot Program,
1636 ?:0 .c .she Center,t?alrig',.\C'7b9,:_1636
13a.N"icld(t,,ptn) Method of test: 24c.For Water Sunnl�_. Tn'i crion "'clis: in addit..•n to Sending the form to
the addi,,b(es) auwc. :.ru :;lu;rut ore .up) ,a this -or.r. within 30 days of
1.1.b.Disinfectiun type: Amount: completion of well cot,>tn: ::on :o the Cu;Irty !:ealtit 'epzrc,ttent of the county
where constructed.
Font 6k% t North Carolina Department of Environmental Quality-Dn isi•,a off.'. ::-,i;i c,s Revised 2-22-2016

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