GW1-2022-00303_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only: j
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1 I
y� I400". ft.
W�y A ft. ft.
NC Well Contractor Certification Number
t� (�` �` 15.OUTER CASING(for multi-cased'wells)OR LINER(if a licable)
WATER WI Z A V J r.�.� , FROM ft. ft.TO DIAMETER'n THIC�'SS MATERIAL
Company Name /'/NG/
`16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. rn•
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER 1 SLOT SIZE THICKNESS I MATERIAL
C Agricultural DMunicipal/Public
Geothermal(Heating/Cooling Supply) E5f.sidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT._
Irrr ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft. n
Monitoring QRecovery
Injection Well:
ft. ft. S"
Aquifer Recharge Groundwater Remediation
::19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ft To ft DESCRIPTION(color,hardness,soturock 'n size,etc.
y� 22 . . �
4.Date Well(S)Completed: V 2-rk Well ID# ft. ft. 14)
Sa.Well Location:
I' ft. ft. Ck re_
a.2 NW1LLN/V/ �/�7L[CCA1 Facility/Owner Name Facility ID#(if applicable) ft. ft. = ¢E 5 fly E L
m d
^ 1 r ft. ft.
Physical Address,City,and Zip
ft. ft.
AW.Snpg
21.REMARKS
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certitleatio :
N 7"Z° f ` a ---w
S,6 W
AA
dF
6.Is(are)the well(s)�ermanent or Temporary Signa of Certified Well Contrac Dan
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: QYes or [. No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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: 3 Q (ft-) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 00'and 2@100') construction to the following:
10.Static water level below top of casing: 2 5 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: ( Y (in.) 24b.For Iniection Wells: In additi i on to sending the form to the address in 24a
r� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: j
(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) 3 Method of test: L7�d to/`v 24c.For Water Suably&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: �� !T H Amount: 1 (O � 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 Resources Revised 2-22-2016