GW1-2022-10308_Well Construction - GW1_20221114

WELL CONSTRUCTION RECO GW-1 For Internal Use Only:
1.Well Contractor-Information:
L • S. 'e h e a a,r- 14.WATER ZONES ?.
Well Contractor Name FROM TO DESCRIPTION
3.5� s ID f`
ft. R
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER tf a licable
FROM TO DIAMETER THICKNESS I MATERIAL
77 ft. ft.
Company Name
3 DD 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(Lu UlG County,State,Variance,etc.) I ft- 9 L fi: 15 7/i/ ia• ll;� Y��
3.Well-Use(check well use): ft. O �.
Water Supply Well: 7:SCREEN
FROM TO I DIAMETER I SLOTSIZE ITHICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft: ft in
[]Geothermal(Heating/Cooling Supply) 4dential Water Supply(single)
ft ft I in.
❑lndustrial/Commercial ❑Residential'Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100 FROM TO MATERIAL EMPLACEMENTMETHOD&AMOuIYr
Non-Water Supply Well: ft. L3+ is ai-
❑Monitoring ❑Recovery A, A g, n,
Injection Well: ,-I
❑Aquifer Recharge ❑Grow Remediatiorr ft. fr.
❑Aquifer Storage and Recovery ❑Saluuty Barrier Ar 19•SAND/GRAVEL PACK if a licable
OC' FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainagoft ft. R
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LING LOG attach additional sheets if necessary)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilirock typN grain si etc
fa ft.
4.Date Well(s)Completed: I/ liZ Well ID# D' ft '�" 6vl i r
5a.Well Location: R' D' 'V i 1, C i,S f
• al t � ft. ft.
Facility/Owner Name 1 Facillipi�ty,M#(if applicable) I
ft.
Ph �tjdresl City,and Zip M OU n ka-i 71 CYv s s ft. ft 3 0
21.REMARKS+1
County J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient)
22.Certification:
6.Is(are)the well(s): ❑Permanent or ❑Temporary a 8 1 Sigoature fie Well Contractor Date
By signing 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 MW ISANCAC 02C.0100 or'75ANCAC 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 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 construction info
construction,only 1 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: 'Z� (ft.)
For multiple wells list all depths yd�erent(example-3Q200'and 2©100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,'use +"1`y Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: .(in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RIC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: -
(i.e,auger,rotary,cable,direct pushk,etc.) 24c.For Water Su 1 and O en-Loon Geothermal Return Wells:Copy to the
county environmental healm department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well producing over 100 000 GPD•Co to D
13a.Yield m Permit Program,1611 MSC,Raleigh;NC 27699-1611 Copy CCPCUA
lgP ) Method of test: rr II-- � �� ut
13b.Disinfection type: Amount: T f✓
0
Form OW-] �a pk
North Carolina Department of Favironmental Quality-Division of Water Reams„"rr..