GW1-2022-01200_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD IGW-1-)
For Inteznal Use Only:
1.Well Contractor Information: s
14.WATERZONES - na5CRWnON
C`Vl FROM TO
ft. R`
well Contractor Name
M ft
15.OUTER CASLYG(for m D������8 uMgTER1Ai.
NC Well Contractor CerdficationNumber FROM TO P Y (✓
�` r G � � is Y
�.l�.�-L056tl ft
1b.INNER CrLSING OR TUBING( thermal etosed3F
CompanyNamc O FROM TO DIA1VIEfER THICKNESS rvraTERrA1
2.Well Construction Permit State variance,etc.)
List all applicable u"ell construction permits X a.UIC,County, ft. ft. in.
3.Well Use(check well use)' 17.SCREEN SWTSIZE TIHCLOi ttIATERLII
FROM TO DIAMECER
Water Supply Well: ft ft in.
Agrieuittmal MunicipallPub&c
le ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft
Residential Water Supply(shared) 18,GROUT E3IIPLACEME-W METHOD&AltotTly r
Industrial/Commercial FROM TO MATERrAL
rAqu,ifer
on i
ter Supply Well: ft. %
nRecovery
oring g, ft.
n Well:Recharge Groundwater Remediation 19.SADID/GRAVEL PACK�TERIAI e 1 vst a�EM ` SHOD
Salinity Barrier FROM To
0Aquifer Storage and Recovery Aquifer Test g, ft.
Stormwater Dratnage It
ft
Experimental Technology QSubsidence Control 20.DRII,LINGLOG attach addltieael sheets If nec n sue etc)
Geothermal(Closed Loop)
Tracer FROM TO IVESCRIPTION(eotor hardness,soiUmek G
eatia Cooling Return) Other(explain under#21 Remarks) ft I ft.
Creothetma!(FI � R,� i. ft.
//��
FUN
(� LZ f„ft.
4.Date Well(s)Completed: 1 0[` Liteli IDY W
l—
5a.Well Location: fr ft_
� � R Facility Wit(if applicable) JiL
Facility/Owner ft ft.
ft.
Pbysical Address,City,and Zip 21.REMARK
�� — Parcel IdmtificationNo,(P1N}
County
5b.Latitude and longitude in degreWmmutesiseconds or decimal degrees-, 22 Certification:
(ifwell field,one lat/long is sufficient) �
N W Date
Si tune of Certified Well Contractor
(were)constructed in accordance
b.Is(are)the Wells) Permanent or Temporary gy igning this farm,I hereby ce"My that the well(s)war
with 15A NCAC 02C 0100 or 15A NCAC 02C_0200 Well
Construction Standards and that a
g [3Yes or o copy of this record has been provided to the well-tuner.
7.Is this a repair to an ezistin well:
Ifthis is a repair,fill out!mown well construcii-n information nd enplain the nature of the 23.Site diagram or additional well details: well site details or well
repair under p21 remark section or on the back of this farm. you may use the back of this page to provide additional
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some
construction details.YOu may also
attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled: l - 1 of completion of well
9.Total well depth below land surface:
(ft) 24a. Forte S� Submit this form within 3U days te-3 00'and 2@1001 construction to the following:
For multiple wells list all depths ifdifferent{cramp �®
{ft) Division of Water Resources,information Processing
'699-1617 nit,
10.Static water level below top of casing: 1517 Mail Service Center,Raleigh,
If water level is above casing,use"'
m 24b.For Injection Wells: In addition to Beading the form to the address f Z l
11.Borehole diameter: t ( ') above,also submit one copy of this foam withal 30 days of completion of well
construction to the fallowing:
12.Well construction method: ound Injection Control Program,
r
tary,cable,direct push,etc.) Division of Water Resources,Underground
1635 Mail Service Center,Raleigh,NC 27699 I636
ER SUPPLY WELLS ONLY: In addition to sending the form to
3 24e For Water Supply&Injection Wails: of this form within 30 days of
Method of test:ALL the addresses) above, also submit one anPY department of the county
(gpm►) completion of well construction to the county health dap
Amount �6 where constructed-
fection type: P—;—A 7_22_2016