GW1-2022-01198_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J Am&'S W 1 1 oN 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
b1` We A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-eased wells OR LINER if a livable
c FROM TO DIAMETER THICKNESS MATERIAL
1 Znc_. ft. � ft. I 'in. �- ` V C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 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. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural r-lMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residenrial Water Supply(single) ft. ft. in.
hldustrial/Cotnmercial Residential Water Supply(shared) 18.GROUT
'Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Pop
ft. f ft.
Monitoring DRecovery
Injection Well:
it. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater 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,soiUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks)
4.Date Well(s)Completed: `� 1_ ; Well ID# ft. 1011
I ft. Q
ft. ft.
5a.Well Location:
ft. ft.
U l�R i�► \LA C=[Z
Facility/Owner Name 1 Facility
�IDq#(if applicable) ( ft. ft.
ft. ft.
P ysical Address,tity,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 lit/long is sufficient) 2 Certification:
N W
A
6.Is(are)the well Permanent or Temporary Si 7NCAC
d Well Contractor ate
By ,I hereby cert fy that the well(s)was(were)Constructed in accordance
7.Is this a repair to an existing well: QYes or No wit .0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information plain the nature ofthe co ofsrecas 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-I 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: "MUD 00 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:
pp ��\�f
10.Static water level below top of casing: 'T'IJ (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: to (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
i above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: -1-�----I-�--S�� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c
13a.Yield(gpin) 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:3b 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