GW1-2022-01184_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
koo 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
_N cw C. (43y� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LII ER if a licable
FROM TO DIAMETER TH[CKNESS MATERIAL
I 0 MR-)
Company Name ,,\\ 16.INNER CASING OR TUBING eothermat closed400
2.Well Construction Permit#:V=— 1 V 3 FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. Ft. in•
hidustrial/Commercial Residential Water Supply(shared) 19.GROUT
Irri ation FROM I TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. OI ft. O a
Monitoring ORecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stomiwater Drainage ft• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) nTraCer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
ft. _R )C6
4.Date Wells)Completed: a� o'13-PI Well ID#b g "10 QL7 I ft I ft.
63 ft- `�(n ft. CMM"'4_P_
5a.Well
Location:
<--•r 1"1 lJ�l\� C.l J ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip
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:
N W l ►at
6.Is(are)the well(s) Permanent or Temporary
rithl5A
f Certified Well Contractor Date
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 No CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information n explain the nature of the 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
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
9.Total well depth below land surface: 1,00u, (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifti fferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:^ty (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
-7 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A 1 �` �V 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) 1 Method of test: '�Z 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: t
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016