GW1-2022-09166_Well Construction - GW1_20220930

WELL C4N5TRUCTION RECORD(GWAl For Intemal Use ODIy: '
1-Well Contractor Information,
,w�.��,1 �1 tAj a�e)/ 14,WATER ZONES
t �
W��YT FROAf TO DEscp PTION
Well CoatractrorNatne ✓L�I G
3 J so- ft.
TIC Wall Contractor-Certification Number 15.OUTER CASING ror multi-cased wells OR LINER a 0cable i
FRO- ^ 70 DIAASETBR TNICKAIE53 MATERIAL
Cs+wrA 1�he v p . ft. it. 4.t in. Q
Company Name 16.1NN£R'CASING OR TUBING(Reothe al dosed-loon
2.WeA Construction Permit#: PRO31 TO Dubt=R BI TCKN RI
FSs MATEAL
List all applicable bull consnvction permits(Le.UIG County,State,Parlance,etc.)
ft. ft. in
ft. ft. ln.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO I DrAAI Ett I SLOT SIZE TRIC[tNESS1 16iATERIAL
❑Agricultural ❑Municipa He U IL Li I! In.
❑Geothermal(Heating/Cooling Supply) t ential Water Supply(A81e) fG ft. In.
❑IndustriaUCo>flmercial ❑Residential Water Supply(shared) 18.GROUT
❑Jm on OWells>100 000 GPD FROM10 I,IATER`fAL EMPLACE�MWINI-MOD&MIOUNT
Non-Water Supply Well:
❑Monitoring.:..;_' ❑Recovery ft. [t.
,Injectfou-WeU:•f ft. ft.
'OAquiferRechaige ". ' ❑GroundwaterRemediation
19.SAND/GRAVEL PACK tra licable
❑Aquifer-StorageandRecovery ❑Salinity Barrier FROM TO bv►T6R^^w. E1tPLACEMENIPAIETNOD
❑Aquifer Test ` ❑StormwaterDrainage Ao B- G� �' e7►
DExperimeatal Technology ❑Subsidence Control n• R'
i 20.DRILLING LOG attaeh additional sbeets If necessary)
❑Geotherriial.(C,losed Loop) ❑Tfacer
FROM I TO DESCRIPTION color.hardoess,tatUroeic In cirr.eta
Meothen»al(IleatindCooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Wel(s)f ompleted: ` �L-2 Well im ft. B'
5a.Well Location: 1p
I�j'IA �GCs�hVlis - rL fL - -
t ' Facility/OwnerNa6 *�FacilityIDB(ifapplicable) S_P
3560C
fL fit art+
-' Wsk8l Address,City,and Zip
r 21.RE51ARKS
i g ^
sty Parcel Taentification�No:(PIN)
5b.Latitude slid longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
-7 N " 7 7.1 Ci"o 3 w ' C) Z-.Z
ti 6.Is(are)the well(s): ermanent -or ❑Temporary
Signature of Certified Well Contractor Date
o signing Oils jarm,I hereby cerro that the mIt(s)was(style)consxacred in accordance with
7.Is this a repair to an e3dsting well: OYes or l3A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that o copy
Ijtblr is a repair, well out known rll construction h(formation and explain the nature ojAre ojthls record lras beery provided to the weft owner.
repair under#21;snarls section or on the back of fhls jarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For deoprobeMPT;or.Ciosed l oop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
construction,only l GW-i is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.T tar well:depth belgw land surface: (3 � (ft.)
Submit this GW 1 within 30 days of well completion per the following:
For rr�ultlple'wel6 IM all depdojrdoerent(example-3®200'and 2Q1001
i 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
fjtaarer level Is above casing,use
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) ANC 27699-1636
Program,1636 MSC,Raleigh,
12.Well•const6ction method:„ �/ o�� 24a For Water Su 1 and Open-Mop Geothermal Return Wells:Copy to the
(Le.auger,rotary,!cable,direct push,etc.) county environmental heal department of the county where installed
FORWATE121SUPPLY WELLS ONLY: 24d.For Water Wells prod Iclnlr over 100,060 GPD:Copy to DWR,CCPCUA,
pp Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
_13a.Yield(gpm) bsethod of test:
13b.Disinfection type: W Amount: 3 d Z 44
Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2019