GW1-2022-01180_Well Construction - GW1_20220121

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
`f i j�/ �/'�/� � ft. ft.
i�1 c \ c- �4o 7 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if applicable)
t FROM TO DIAMETER THICKNESS MATERIAL
�n ft. t ft. © in.
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ram)bY� 1-j� 3 5 3 ft. ft. in.
List all applicable well construction peIC,County, ariance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
:)Industrial/Commercial Residential Water Supply(shared) 19.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 1 ft. C
Monitoring ®Recovery
Injection Well:
ft-Lft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) ft. • ( ft.
4.Date Well(s)Completed: _b. Well ID —.# '-) ft. 1 ft. SAW IEft. ft. t
5a.Well Location:
a4�� _t �b ft. ft.
\ 1N17�1 i'
Facility/Owner Name �p Facility ID#(if applicable) ft.
` ft. ft.
r 6�81 V� 1\l� 5ii DIPE N� ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
�( N W rr
6.Is(are)the well(s)#)CjlPermanent or 13Temporary Si ture of Certified Well Contractor Date
1 By 'gning this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes oro �wi 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 informationlnaVxplain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. 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: i SUBMITTAL INSTRUCTIONS
y ``--t
9.Total well depth below land surface: /;4p (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (96/ _(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: CS! (in.) 24b.For Iniection 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 well
12.Well construction method:4 t��(f )�t`) 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
13a.Yield(gpm) Method of test: (IZ 24c.For Water Supply&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: C l e' 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