GW1-2022-00268_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
A,/f G' v� Tom N 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor NameO ft. 1 91 ft. 5 0M
/ 7t/f Q ft. 3. ft. 10 C'1 P.m
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OI LINER(if a livable)
- f ft-r 15 1z , rs.z�'7,�l NIC, FROM TO DIAMETER I THICKNESS MATERIAL
Imp W O ft. C)ft. 1 in. G z/0 VL'
Company Name 1-'^^ '46.INNER CASING OR TUBING(geothermal closed-loop)
V v _
2.Well Construction Permit#: .1 , ^ 035 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
:Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.'
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ft. NEAT, mit S /bs
Monitoring DRecovery
Injection Well:
Aquifer Recharge oGroundwater Remediation
' 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage
:)Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
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FROM TO DESCRIPTION color,hardness,soil/rock t e, in siu etc.)
Geothermal(Heating/Cooling Retum) !- Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 12-6 Well um
5a.Well Location:
(3ET44 C oa(za.�.
Facility/Owner Name Fayccility I (if applicable) ft. ft. J E r 2 d 29 ZZ
332er l Gmee-NIRREPrik i/„ ft. ft. y
Physical Address,City,and Zip ft. ft. i' G'P,tOI Ov
>21.REMARKS
County Parcel Identification No.(PIN) INSTOL L I-XN91Z TO AEPE.W-15
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: TEXT oil ftTz tj C C ristmG
(if well field,one lattlong is sufficient) 22.Certification:
3(v. 030-790G N -?gt0120005 W Ahbv_ a-5-aal
6.Is(are)the well(s)f2rPermanent or E3Temporary Signature of Certi ed Well Contractor' Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: gYes or DNo 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 3 4 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l
11.Borehole diameter: (in.) 246.For Iniection Wells: In addition to sending the form to the address in 24a
R orARtJ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY CWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: pg m P 24c.For Water Supply&Iniection 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: NF-r N Amount: 6 0 Z completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016