GW1-2022-10279_Well Construction - GW1_20221114

WELL CONSTRUCTION ION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inforrm�a�tion: 14.
U-6 1 yu / f �U t�l� 1 V f /�C Ol u I V FRO ATER Z ONES DESCRIPTION
Well Contractor Name.�9 ft. �{s tt' c,L/�,l-96
Ada b ' y� b`; t/0 rt. iJ✓ ft
NC Ziamctor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if il licable
FROM TO DIAMETER THICKNESS MATERIAL
Oft �' rt /pn
Company Name 16.INNER CASING OR-TUBING geothermal dosed-loop)
`.�-� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#!: Uw 11 ft. ft. in.
List all applicable well construction pennits(i.e. r otuup.State, Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. iri•
❑Agricultural ❑Municipal/Public
tt ft.❑Geothermal(Heating/Cooling Coolin Supply) eidential Water SuPPiY(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD fAMOUNT
❑Irri ation 0 ft.
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if n licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO it. MATERIAL. EMPLACEMENT METHOD
❑Aquifer•Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soll/roch type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) v' ft ft. e
4.Date Well(s)Completed: `s a '2 O ft 6 ft. 6W tV SAP I P j4 61,14 F
ft ft.
5.Well Location: ft. ft e
1 �
` o ` bnI-1z�­ T 1- 2 6(eft- 62 96 ft- 4 E
Facilily/oAr Name Facility ID#(ifapplicable)
IL ft
ft ft.
Physical Address,City,and Zi �.
21.REMARKS
County Parcel ldentificatlonNO.(P ) NOV 1 4 2022
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) Information f r ;,e v is J ll;It:
ll, 9S �o N 8 a a Qs� W ��a tax ,
2
i , Si ire of Certified Well Contracto Date
L�P 6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I hereby certify that the ivell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [BNo copy ofdtis record has been provided to the ivell owner.
V'lhis is a repair,fill out known ivell construction hiforniation and explain the nature ofthe
repair under#21 remarks section or on the back of this Joan. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed' construction details. You may also attach additional pages if necessary.
For multiple byection or non-water supply wells ONLY ivith the sane construction,you can
submit are form. 24.Submittal Instructions:
9.Total'well depth below land surface: t�2 7()/\y (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100) construction to the following:
e 10.Static water level below top of casing: c 3S (ft-) Division of Water Quality,Information Processing Unit,
if hater level is above casing,use"+'' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�D /A (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well c truction method' P7 s construction to the following:
(i.e.auger taty cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
n 13a.Yield(gpm) Method of test: 9/ 24c.For Water Sllpply&Geothermal 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: Amount:
/X t completion of well construction to the county health department of the county
where constructed.
Fonn G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013