GW1-2022-09118_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well 'Contractor Information:
WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 3 S `fS Ve i vt - !S 1�
1 -15.OUTER CASING for multi-cased wells OR LINE if a- Crcable
Q►1.S�2N S well r� '1\rt FROM To DIAMETER THICKNESS MATERIAL
'h C ft. 2'7 ft in. O A 1 0 ��+
Company Name
�7 16.INNER CASING OR TUBING eothermal closed-loop)
q -
2.Well Construction Permit#: 1 (� ! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft
3.Well Use(check well use): R ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic It. g, in.
❑Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) n. ft ut.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL CEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 3 ft '�oc+ k� 24
❑Monitoring ❑Recovery 3 ft a,p ft. q @� u
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERW. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. IL
❑Experimental Technology ❑Subsidence Control ft R.
❑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 e, in dze,etc,)
IL ft
4.Date Well(s)Completed:09.JoLaaa wen ID#- 30 1q7 fL �p p rt
5a.Well Location: � ft. 6 ,ft. . ve th
1 Drrvv► �rrYi��'1 i'f 2r
Facility/Owner Name Facility TD#(ifapplicable) ft ft
Physical Add"City,and Zip ft ft.
Greco Y 1`I I If- 21.REMARKS 'p i
County Parcel Identification No.(PIN) tr y 2`'n
22
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees: -
(if well field,one tat/long is sufficient) }
22.Certification: 'D`1A..)r'-.;t?C
31Q• 0 CFO N
6.Is(are)the well(s): 411'ermanent or ❑Temporary Signature of ttilfed we ntractor Date
Ilvsigning 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 W140 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 and explain the nature of the of this record has been provided to the ivell 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 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �5- (ft.) Submit this GW-1 within 30 day's of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@ 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: of D (ft) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is shove casing,use"+"
11.Borehole diameter: (in,) 24b.For injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,N627699-1636
12.Well construction method: I JZOTi4 R� 24c.For'Water Supply and Open-Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) Method of test:
��pp 6
13b.Disinfection type: C.+1�0►�t Qi Amount: �D
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018