GW1-2022-01181_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
_1.Well
Contractor Information:
,JAPAE5 A n n 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
�`-c Y r ? ft. ft.
' \hr� L4 VQ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a livable
s �O `„ _ FROM TO DIAMETER THICKNESS MATERIAL
1 l ft. t ft. 95' in. �C
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: �`�— I I FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Mun ipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 19,GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft U i ft. G Grg I
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge n 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 [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) [3 Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPT ON(color,hardness,soii/mck e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft. ft.
4.Date Well(s)Completed: ( Well ID#OPP� 115 7 ft. I CD ft. t
5a.Well Location:
�
l�1 i,r� 6
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
N W t
6.Is(are)the well(s) ermanent or Temporary tmit ]M
of Certified Well Contractor Date
g this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well ®Yes Or O NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe is 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: 1. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
r i
10.Static water level below top of casing: I ) (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,/use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l Q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�n t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 14 1 Iz / I\U Z 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) I lL Method of test: 4 1, 24c.For Water Supply&Iniection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: k PeMgj 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