GW1-2022-10676_Well Construction - GW1_20221205

WELL CONSTRUCTION RECO GW-1
�� For Internal Use Only ;
1.Well CAAractor. r. I
14.WATER ZONES
Well Contractor Name FROM TO DESCRDYr70N
3'S3s pry � �. 2022 laoft'
NCWcUContractorCertificationNumber �fi`raF R l;fs iG,
�L,r,i3i3 * )� IS.OUTERCASIIVG for multi-cased wells OR LINER Ifa lieable
(�/YL/ r{ •DIAMETER THICKNESS MATERIAL
-. ',] a FROM TO
Company Name ft ft i in.
(� (/ D ZZ.. Da .� 16.IIVNER CASING OR TUBING othermal closed-loop)
2.Well Construction Permitmr—KW�r O I FROM TO I DIAMETER THIC[OVESS MATERL►I,
List all applicable well constructlonpermlts 0.e.WC County,State,Varlaneq ela) . �,I R 'L 3' tt � �f, 7 ,/ in
O . -1—h •C
3.Well-Use(checkwell use): R
Water Supply Well: 7:SCREEN
❑A cultural FROM TO DIAMETER SLOT51— THiCtoYESS MATL�RW,
gn ❑Municipal/Public ft ft is
❑Geothermal(Heating/Cooling Supply) *idential Water Supply(single)
ft in'
❑lndustrial/Commercial ❑Residential'Water Supply(shared) ft
Is.GROUT !'
01n-i atiop ❑Wells>100,000 GPD FROM TO MATERW, EIFIYLACEMENTMETHOD&AMOUNr
Non-Water Supply Well: - ft: it
❑Monitoring ❑Recove
Injectioawell: rl' - . -- 23 ft-` AA i -f-k
❑Aquifer Recharge ❑Groundwater Remediation ft -1
aL
OAquifer Storage and Recovery ❑Salta*tyBarrier 19.S&ND/GRAVELPACK(if applicable)
FROM TO MATERIAL EM IACEMENTMETHOD
❑Aquifer Test ❑StormwaterMainage ° ft. ft
❑Experimental Technology ❑Subsidence Control' fa ft
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG f2tinch'addi'oral sheets if necessa
❑Geothermal(lieating/CoolingRetum) ❑Other lain under#21 Remarks) FROM TO DESCRUMON color hardeess soilfrock in ske,eta
ft ft
4.Date Well(s)Completed:. �Z . Zy well ID# ft ft
52.Well Location: ft. it
ft ft
Facility/Owner Nauia VFacility M#(ifapplicable). ft ft:
ft it
Physical Addrek City,and Zip ft j ft
So,r rm 21.REMARKS1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if2welll field,one lat/long is sufficient) Q 22.Certification:
w
6.Is(are)the well(s): ❑Permanent or. ❑Temporary 2,3 Li Sigoatura ofCerttfiedWell Contractor Date
Byslgning thisfoim,!hereby certi&that the wells)way(were)eonsnvciedin accordance with
7.Is this-a repair to an existing well: ❑Yes or ISANCAC 02(7:0100-or'7SANCAC 02C.0200 Well Cpnstruction Standardr and that a copy
Ifthls is a repair,fill out knaHm well comimetlotftnforinat/on and explain the naiure ofthe of this record has beenprov/ded to the well owner.
repair under#21 remarla section or on the backofthisform.
23.Site diagram or additional well details:
S.For GeoprobeMPT 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 Rdniarks Box).You may also attach additional pages if necessary,
drilled:
1 ^O 24•SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: w ft '
Formulliple wells list all depths 1Jd/fferedt(example-3(n)200'and 2Q100) ( ) Submit this GW 1 within,30 days of well completion per the following:
I
30.Static water level below top of casing: 2- d (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above caain&}use"+ Information Processing Unit i617 MSC,Raleigh,NC 27699-1617
f�J i
11.Borehole diameter: ,+O (m) 24b.For Infection Wells.Copy to DWR,Undergmund injection Control PC)
Progrimi,1636 MSC,Raleigb,NC 27699-1636
12.Well-construction method: I , .
(Le.auger,rotary,cable,direct push,etc,) — 24c.For water SunDly and ODen-Loop Geothermal Return wells Copy to the
county environmental health,department of me county where installed
FOR WATER SUPPLY WELLS ONLY:
GG 24d.For water wells Dr lducine over 100 000 GPD•Copy ft DWR,CCPCUA
13a.Yield(gpm) J � Permit Program,1611 MSC,Raleigh;NC 27699-1611 Method ofteste I tt
13L Disinfection type: Amount.
Form OW-1 North Carolina Deparmient ofEaviroumental Quality.Division of Water Resourc&v