GW1-2022-01176_Well Construction - GW1_20220121

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
w c—:5 'Do y)1e—1 W 1 bon 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
/+���/� �7 ft. ft.
Uc l— n./03 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi cased wells OR LINER if a licable
HIC
r r �11`1 1 1 " FROM ft. TO ft. DI I A5 in. 1,5 Tpral S [�`/
Company Name ` U 16.INNER CASING OR TUBING(eeoothermall close d-lon C T
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 1
Monitoring ®Recovery ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SANDlGRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type, rain size,etc.)
Geothermal(HeatinglCooling Return) nOther(explain under#21 Remarks) ft. t ft.
4.Date Well(s)Completed:13'f 4-11_ Well Em D• 1.+ 1 ft.
ft.5a.Well Location: ft.
I�� ` n e� ft ft.
Facility/Owner Name W G Facility ID#(if appliccaab(llee)/� ft. ft.
� R I p�U'1 f✓ ft. ft.
ft.
Physical Ad ss,City,and Zip V ft.
(�(' e—vm Kee 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
t
N W �-F-
6.Is(are)the well(.) Permanent or Temporary ignature of-Certified Well Contractor Date
signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o ith 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 nd explain the nature oft 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
constructioq,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
d� f
9.Total well depth below land surface:l(X D (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@200'and 2@100) construction to the following:
10.Static water level below top of casing: c-A�1 (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: Q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
t, "R 1 (` , m) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t 1z q �CY� — construction to the following:
(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
t
13a.Yield(gpm)J(, Method of test: 1 24c.For Water Supply&Injection 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: Amount: 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