GW1-2022-09735_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD (GW-I) i For Internal Use Only:
1.Well Contractor Information:
14.WATER 7ANE5 1
FROM TO DFSCRrPT10N
WellContractorName
NC elrl Co'nttrrac{ttoon.cortilication/Number t{1 t , r� 15.1OUTER CASING for 11 TO multi cased wells OR LINER if a livable
w O i``�P- ��yl v J r 11 R, R. D a In. 'rtDCKN1=5S �SnTER1AI.
1 ti� mac.
CotnpanyNamc ^ 16.INNER CASING OR TUBING eothermnl clmcd-loo
/��� p wR �Q FR031 TO DIAMETER TffiCHIVFSS hL1TERIAI
2.Well Construction Permit M ft. ft. In.
List all applicable ivell constmcdon permits(f e.UIG Counp;State,Variance,etc.)
!t. ft. In,
3.Well Use(check well use):
17.SCREEN
Water Supply Well: PROM TO DUM>tsR SLOTSI2E TIDCIO9PSS MArSRiAL
❑Agricultural ❑Mtmicipal(Public � IL 7 fL . in, G Li PVC.
❑Geothermal(Heating(Cooling Supply) M Sijen-tial Water Supply(single) M ft I16
OIadustriaUCotfllnt rcial ❑Residential Water Supply(shared) 18.GROUT
0hrigation ❑Wells>100,000GPD 6FRTO MATEa L EMPLACE'mNr?-rmOD&A.\rOUNT
Non-Water Supjily Well: fL - ' ' `%v❑Monitoring - ❑Recovery fL ft.
DAquifer-kahaige ❑Groundwater Remediation RAVEL PACK ire livable❑Aquifer Storage and Rewvery ❑Salinity Barrier To hLAL'Mi IAIE lfpr AcenlENr :tErsOD
❑Aquifer Test ❑Stormwatcr DrainageR•❑E erimental.Teehuolo ❑Subsidence Control fL
pGeothetriral,(Clased I oop) OTracer 20.DRILLING LOG attach additional sheets if neeess
1 FROM TO DESCMTION color hardo 02mek 1a"M etc
❑Gcothermal(Heating/Cooling Retuiii) ❑Other(explain under 421 Remarks) LoAM 1
4.Date Well(s).Completed: Aa:• Well M#
fL ft.
5a.Well LoeatIan:
t LX 1.�y\,ara� it. -rL
ft. ft.
Facility/OwnerNaine ,Facility Mfi(ifapplicable)
� ft. �-,
�,.-
j. .. EF
Physicot•Addcess,City,and Zip '
21.REnfARKS�- 2
` - County is Parcel'IdentiEeation No.(PIN)
i•, .:
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r_--, J
Ift,Liri.a9•,.�1 r t:%•J anY,,::, ,H
r"14. (ifivelilfield;one•lathong is sufficient) 0 22.Ce teatiou: ) �h;?•'Qi hT I
WW,,//(vJpa\ -fir/// J o^wr��
6.Is(are)the �
(s): t�Per//--manent or, ❑Temporatry Signature of CertiEed Well Contractor Date
- -• lvell . '
i I` / By signing thIs form,1 herebv certo that the well(s)ivas(mvrq)eonuructed in accordance with
Oyes bt• ONo ISA NCAC 01C.0100 or ISA NCAC 02�C.0200 Nell Construction Standards and ihar a copy
7.Is.this a rep lr to an eristing ioell: ;
!flhtr is a repafr-'f ql rm out Imo iwil.�thnst itctian information and explain the mature ofthe of this record has been provided to the xell owner.
rrpair under tt_11'RIemarks secllon or on e back of thisjorm. 23.Site diagram or additional`well details:
I. You may use the back of this page to provide additional well construction info
,ir• '• 8.Fof GeoprobelpPT--ok:C9osed-L,00p Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction;only 1 GW;]is-nee&& Indicate TOTALNUMBER of wells
dt'illed: - - 24.SUBMITTAL INSTRUCTIONS
9.T taI well dgpth;below land surface: (ft') Submlt this GW-1 within 30 days of well completion per the following:
For rr�ulhpleii�lls 11se.a11'dgpths.Pfdifferent(example-3Q200'and 1Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
-I9,,Static watet�leveltbelow top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
later level Is a`ove casing,use ++-:
24b.For Injection Wells:Copy to DWI?,Underground Injection Control(RUC)
11.Borehole dtalneter.
`I' tmProgram,1636 MSC,Raleigh,NC 27699-1636
12.Well constfttction method: Y1 V 7 � 24c.For Water Supply and Open-Loop Geothermal.Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) coly environmental'health depamnent of the county where installed
tl
FOR!�W-ATEWSUPPLY WELLS ONLY: 24d.For Water WeUs producing over.100 000 GPD:Copy to DWR,CCPCUA.
q`f, Permit Program.1611 MSC,Raleigh,NC 27699-1 1l
13a.Yield(gpm) �O Method of test:
13b.Dlshtfecton.type: e-V�1�`r�� Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 6-6-2018