GW1-2022-00281_Well Construction - GW1_20221222

V1 Ja AjLj 1%NX—%JXL" For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Inf�orr�mation:
�tJ•1 1�/ ! t ! /u �� S 14:WATER ZONES- ' k. ..
t u FROM TO DESCRIPTION
Well ConttaetorName It.
_ (/
• 15 OUTER CASING for'molti-cased wells OR LINER if a"licublc
NC Well Contractor Certification Number
FROM TO DIAMETERTHICI4VESS MATERIAL
. r",i (,��,Z: 5 w e kL -Dr 1 I I i n 00 ft 6 ft. O8 In. 1 125 1 je 1J,
Company Name 16ANNER`CASINGOIRIUBING `eotbermal crosed400 `'`-'i: '
/�j FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:� � L.,l . ft. fL in.
List all applicable well construction permits(i.e.Counq;State,Variance,etc.) ft ft in.
3.Well Use(check well use): _17:SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft• •' in,
❑Geothermal(Heating/Cooling Supply) Widential Water Supply(single) ft. ft' rn`
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation ft b ft er7 dk;
Non-Water Supply Well: ft, ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL:PACK in `livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it. ft
OAquifer Test ❑Stomrwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG tittachtadditionalsheetsifneceI
OGeothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soilfrock type,graIn size etc)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) Q L ft.
4.Date Well(s)Completed: f 2 Z b ft 6 eU-u
ft 0 rt da
5.Well Location: ftb16
�it
Facility/ wner Name Facility ID#(if applicable) J r` t ' 1ft
—�; _
ft ft
g0 l ,�I1►1-�ru Yn �.h. me>br�SPfL = ft. e�- '
Physical Address,City,and ip �er '
.21.REMARKS
•Zr i P II D17 2 9, OZZ
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWQi30C-
(ifwell field,one lattlong is sufficient) /�tt,, /
(00 N ? Lo !1 5-CS 6 W AgA ra
�� t�
���� Si ture of Certified Well Contraolo Date
6.IS(are)the well(s): A ermanent or ❑Temporary By signing this form,I hereby certify'that the well(s)was(were)constructed in accordance-
�� with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy ofthis record has been provided to the well owner.
lfthis is a repair,fill out Imosm well construction information and arplain the nature of the
repair under#21 remarks section or out the back of thisform. 23.Site diagram or additional well details:
p 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 injection or not-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
t 24a. For All Wells: Submit,this form within 30 days of completion of well
9.Total well depth below land surface: ��l�d (ft) r, Y P
For multiple wells list all depths ifdgerent(example-3@200'and 2®100) construction to the following.
10.Static water level below top of casing: 1�d (ft.) Division of Water Quality,Information Processing Unit,
If water love!is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 246.For Infection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auge rota able,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
13a.Yield(gpm) U Method of test•• — ) 24c.For Water Sunniv&&Geothermal Wells: In addition to sending the form to
J j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: // Amount ) completion of well constructi nn I to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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