GW1-2022-01189_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD(GW-1) For Inteaoal Use Only:
1.Well Contractor Information:
( ,I•'ma i IFt►� lal 4��y� n FR MATERZ TO
DESCRW1IOn
WellContractorName g• ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING{for vable
z FROM I TO DIAMETER THtCKl'M MATERIAL
fL
Company Name
16.INNER CASING OR TUBING(eotieermal closed-tun
FROM TO DIAMETER TBICtINEss MATERIAL
2,Well Construction Permit#: ft, ft. in
List all applicable well construction perm (Le
w e.UIC,County,State,Variance,etc.)
ft. ft.
3.Well Use(check well use):
17.SCREEN
Fa Well: FROM To DraMETER sLOTSIZE THICKNESS 0MunicipaVPublic ftvft 9nlleating/Cooling Supply) Residential Water Supply(single) ft.mmercial Rsidential Water Supply(shared) ISGROUT
FROiVf TO kMATERIAL EaIPLACEM METHOD B� ft •^) (ft i1
Non-Water Supply Well: }�t
Monitoring ft. M
Injection Well: ft ft.
BAquifer Recharge Groundwater Remediation 1g,SAND/GRAVEL PACK if a liable
Aquifer Storage and Recovery Salinity Barrier FROM TO MAT=abl EMPLACEMENT VW OD
Aquifer Test E)Stormwater Drainage ft• ft'
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additionalsheets neeess
FROM TO DESCRIPTION(color,6ardaess,soil/melt r, a size,etc)
Geothermal(Heating/Cooling Return) Other(explain under n21 Remarks) ft 44 ft
4.Date Well(s)Completed:1��I'� ID
,L We11 # 1 ® " �i
� T fr• �
Lft.Well L cation:sft1 Facility IDO if applicable)
fL fL
Facility/Ownerevame tY (
c ,� fL ft.
ft fL
Physical Address,City,? Zip
���',E 1�� �L� _ 1 21.REi47ARKS
� Zl
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field,one latrlong is sufficient) 22.Certification:
"' Gw i'A
Si of Certified Well Contractor Date
b.Is(are)the well(s) or Temporary `
By si '.g the farm,I hereby certify that the well(s)was(were}constructed in accordance
7.Is this a repair to an existing well: QYes or No with 5A NCAC 02C.0100 or ISA_IVCAC 02C.0200 Well Construction Standards and that a
If this is a repair,flit out known well construction information nd lain the nature ofthe ofil is retard has been provided to the well owner.
repairunder 421 remarks section or on the backofthis form_ 23_Site diagram or additionalwell details:
8.For Geoprobe/DPT or Closed Loop TGeothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
constructioq,only 1 GW-I is needed Indicate TOTAL NUMBER of wells
drilled: 1 l SURKITTAL INSTRUCTIONS
d >
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 f different(ezample-3Q200'and 2Q1001 construction to the following:
t 10.5tatic water Level below top of casiag: (fL) Division of Water Resources,Information processing Unit,
Ifwarer level is above casing,use`+" 1617&tail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
a ` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct past,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 276991636
c.� q Y
13a.Yield(gpm) ( Method of test �� 24c.For Water SupT)l &Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
�,, p'� �� completion of well construction to the county health department of the county
13b.Disinfection type: Amount:(7l J
where constructed.
Revived 2-22-2016