GW1-2022-10564_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor i� Information:e✓)0_42b rb ,44.WATEWZON ES,,f_t.
_ � I`
FROM TO DESCRIPTION TION
Well Contractor Name w r 7
NC Well Contractor Certification Number :1$iOUTEWCASING.`foc;muIt!-:Fase-d*6Ils ORL7NER`if a-'llea—w .
f 4 /(aJ� I ,;�i A � FROM T DIAMETER THICKNESS MATERIAL
(/�/�H_ V I/ S ft. O ft. in. k_q10 tlG
Company Name
P Y '36INNERCASINGOR ING("eothermalclosed=iuo"�,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
aterSm 1 Y7!SCREEN,�k
W
Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS ' I MATERIAL
Agricultural U;e'ide,tial
un ipallPublic A ft*
ft. in.
RGeothermal(Heating/Cooling Supply) Water Supply(single) g, ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R' 60 tt' bA� a
Monitoring Dr,,oery ft. fa
Injection Well:
Aquifer Recharge E3Groundwater Remediation
t;]9:SAND/GRAVED:PACK;rfe""lieabiev.�,a.€:; y,_��v:•r ,tias'E' sr..y.� "r� '�
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer :20:DRILLINGILOGi attach additional ihat-slit neecessa tf s ;, r s K
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,saWrock n sfine etc.)
nn ft. ft.
4.Date Well(s)Completed: Well ID# R' R'
ft. ft. " ° /
5a.Well Location: E 9
ft. ft. - `"
Facility/Owner Name Facility 0#(if applicable)
C4 10 4 U 0 1UL 7� 6�V o.76-
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weefl field,orle lat/lon'g is sufficient) 22. rtification:
s"O_�_ I� 1 N ?ez�G95_f ?r 7.2 W
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well- es or 13No 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -7 SUBMITTAL INSTRUCTIONS
—
9.Total well depth below land surface: /12 (ft-) yqa, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example- @200'and 2®100') construction to the following:
10.Static water level below top of casing: 0C e5' (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. II"1 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Y) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ka 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
13a.Yield(gpm) Method of test: (/1 i 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �T �1 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou"ces Revised 2-22-2016