GW1-2022-09345_Well Construction - GW1_20221010

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatiio�onnn:
�7lnvi 44:WATEWZONES� `'.FROM TO DESCRIPTION
Well Contractor Name y� gsft. c(p ft. Pilk, e-c-"l/G
32�ft. 3 3O ft. l yi �P
NC Well Contractor Certification Number 13 OUTER':'CASING..forpiu`Id cased tGells")sOR'LtNER'if,a"`llcetil� '
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 90 ft. in.
Company Name
16ANNER,CASING - v
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. j 1O' Joe(--
3.Well Use(check well use): ft• ft. in.
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13 unicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
IndustrWCommercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOl1NT
Non-Water Supply Well: ft. ft. 3�g It y L. 61 GY
Monitoring 'Recovery ft. ft. +�
Injection Well: ft. ft.
Aquifer Recharge E1 Groundwater Remediation w
:<�9.SAND/GRAVEI;;PACKarf.a`".licab'le� _ .= �;.,":•=,i
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20`DRILLING`.LOG ettiei?h additidiiisl sheets'if,n
Geothermal Heatin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color he,dn soiUroek n etc.
19 ft. ft. rt
4.Date Well(s)Completed: '27iWe11 ID# ? ft. Q ft.
5a.Well Location: ft. ft.
kid 1
ii�� t 4
zac-�(.o Met'5
Facility/Owner`Name n �yFacility ID##((if applicable) ft. ft.
:a;r
ft. ft. 2022
Physical Address,City,and Zip 21 REMARKS County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
75 3 3 6 W z -A 2-2q-zz
6.Is(am)the wel(s) rmanent or Temporary Signatur Certified Well Con or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or MKO 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 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: '�/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3!0 (R•) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@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: f0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
L above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4)z-.r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: jd/h,J7 , J& 44c•For Water Suooly At Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: jU 7HAmount: d S completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources`` Revised 2-22-2016
I,