GW1--03282_Well Construction - GW1_20230511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name R �
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NC Well Contractor Certification Number -+
OUTER CA�SII+IG for uiiil4a�sed:ivells'OR IiINER�rf.a- `•cable °.. .
/�/�� n \ �''I I s` �� FROM TO DLA21iEfER n THICr{l�'FSS ➢LaTERIAL
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Company Name K 16;IDiivE t CASING ORTUMWG `eotl>Q[mal closed=loo'
2.Well Construction Permit# O I FROM TO DIABIEtER THICKNESS MATERLAL
List all applicable well construction permits ft e.DW County,State,Variance,etc) ft m
3.Well Use(checkwell use): % m•
Water Supply'A'ell: ;FRMAII E TO DIAIIEIER SLATSIZE THICAN'ESS IIIATERLAL
_-, Agricultural Obiunicipal/Rmblic ft ft. in
Geothermal(Heating/Cooling Supply) Residential
esidential Water Supply(single) & ,a
: Iudush"ial/Commercial Water Supply(shared) 18.GROUT
—11nigation FROM TO AUTERrAr. ENIPL-ACEilIENT 11IE HOD&AMOUNT
Non-Water Supply Well: 0 & b en ,i it
Monitoring DRecovery ft. IL
Injection Well: ft. %
Aquifer Recharge Groundwater Remediation
&ANDlGR4VELYACg Ufa' 'lim6iel
1 Aquifer Storage and Recovery DSa11Dity Bather FROM I TO MATERIAL EYi'IPL&CEMENT METHOD
Aquifer Test OStorm-aaterDrainage iti tL
._ Experimental Technology QSubsidence Control ft %
RGeothermal(Closed Loop) +_: Tracer tioriaYstieets'ifi;eceua
Geothermal(Heating/Cooling Return) Other(e. lain under 21 Remarks) FROM TO DESCRIPTION(color.bardness softock e, si7A etc
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4.Date Well(s)Completed: J L�Well nw 40 7 6 f O('Vn Cil I
5a.R'eR Location:
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Facility/Owner Name Facility ID=(if applicable)
Ballaf4 11� IL �, t.P3 �i
Physical Address,City,and Zip M A Y 1 20 23
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County Parcel Identification No.(PIS Un
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
C.S­ylS0 N 81.DOM?7 W V -�-Z3
6.Is(are)the well(s)IOPermanent or E3Temporaty Si_ e of Certified Well Contractor Date
By signing this fornb 1 hereby certify that the well(s)was(were)constnucted in accordance
7.Is this a repair to an existing well: QYes or No with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knouvr well corstn:ction information run explain the nature ofthe copy ofthis record has been provided to the well owner.
i repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Tells having the same You may use the back of this page to provide additional�vall site details or rvell
construction,only 1 GW-1 is needed. Indicate TOTAL NUIVIBER of wells construction details. You may also attach additional pages if necessary.
drilled: e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z. J (B•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di fferent(example-3@200'and 2 a1100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"� 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
��� above, also submit one copy of this form within 30 days of completion of mvell
12.Well construction method: t 61 4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Prograrn,
FOR N'VATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) DFethod of test: 24c.For Water SumVLv&Injection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �l % Amount: /0 O-7[.� completion of wall construction to the county health department of the county
where constructed.