GW1-2022-00971_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
e 14.WATER ZONES
WdlConWactAName FROM TO DFSCRI]MON
ZZ !A ► AJ ' ft. 3,OV ft.
1 o ,7
NC Well Contractor Certifican Nmbe o 5
15 OPIERING ormuwes
ble
FROM DIAMETR RIIA MATE RL1L 1I
Company Name n 7-7 ft �' t�'a �� Y
16.INNER CASING 1 OR TUBING cother nal desed-loo
2.Well Construction Permit#: �3 `� FROM TO DIAMET E[t ffi(SQIFSS MATERIAL
List all applicable well awmtruction permits(te.VIC,County,State,Yarimec,,eta) & M in.
3.Well Use(check well use):
IL
& in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNFSB MATERIAL
Agricultural [3MunicipaVPublic U & & in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) & R in.
Industrial/Commemial Residential Water Supply(shared)
iR GROUT
Irrigation 79i
MATERIAL CEN ZNT OD&AMOUNT
Non-Water Supply well:Monitoring Rvery Injection well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK des 'able
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL. EMeI.ACF1Nd'rr METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control % ft.
Geothermal(Closed Loop) DT-cer 20.DRILLING LOG attacJ additional sheets if necessa.
Geothermal(Heatng/Cooling Return) Other(explain under#21 Remarks) FROM To DEseeIPTTON cold,radoes,soli/rodc sae eta
4-DsteWelisCplete : Well ft r Y TAU ''
58.We11'Location: S Tr ft
Facility/Owaa e ITT Facility lD#(if applicable) N I
ChiiPT V►��oh, n1 CS3 p
physical Address.CRY, tL ft.and Zip JH
C .cn Q c0ann
2L REMARKS
Comfy Parcel ldeotilieaRion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latfloag is sufficient) 22.Certification:
O� N wI"I -R I
1
6.Is(are)the well(s)aPermaneut or Temporary Signature of Cchfied Well on er Date
By signing this form,I hereby cen6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill out known well construction information fmdeiplaln the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarAs 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 thispage_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: - I or SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D s (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esample-3 r@200'and 2@100) construction to the followin
10.Static water level below top of casing: 3D (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:• n (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 We11.rnLtstrnetion method: J'1 )2 ®/ �7 above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i a'anger,rotary,cable,direct push,etc.)
Division of Water Rescm ces;EUndergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
R
13a.Yield(gpm) OZI Method of test: 1 24c.For Water Supply&Iniection WeOs: 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: 9�i Amount: P'Z 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