GW1-2022-01199_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
\ 1.1Wen Contractor IInnformation: r C
V I'ti 1`1C�� l\s �.�I l lJ U n 14.WATER ZONES
Well Contractor Name - FROM To I DESCRIPTION
p ft. ft.
ROW-1L V - ��u TO[mot"� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
I r �\�,A,`` r�+ FROM TO DIAMETER THICKNESS MATERIAL
1��1 ben W 6 1 1z;11 1 r1 R a-V)A.-, � et. t ft. 0,15 in. 7YL
Company Name ` 16.INNER CA G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: b 4;)- I l�q 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
Industrial/Commercial ®Residential Water Supply(shared) 18.GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b
126 ft. i ft. lZ
Monitoring ®Recovery ft. ft.
Injection Well:
9-1 ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. Lo , It.
4.Date Well(s)Completed:1 I off— Well lD#b,_Q-C`0R LQ
ft. lob I ft.
ft.5a.Well Location: 'ft.
. ft. ft.
I
Facility/Owner latne J Facility ID#(if applicable) ft. ft.
l� �k► t ;� lh. ���Sti�l[e n�c, ft. ft.
Physical Address,City,and Zill ft. ft.
5ogma0Qg37 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:
.Q6. N Wr5A
Is(are)the well(s) Permanent or Temporary rtified Well Contractor Date
form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes orNo 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informatio an explain the nature of therd 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: (ft.) 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:
1
10.Static water level below top of casing: (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: (0 (in.) 24b.For Injection 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: V-t t R / �(Yf b.I Zl ) 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
r
13a.Yield(gpm) Method of test 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:(,_19r') 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