GW1-2022-01201_Well Construction - GW1_20220121

Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print
1.Well Contractor Information: `
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2 ft. ft.
a -404 ft. ft.
'NC.W`\ell Contractor
lCertification
tlNumber �j r1 15.OUTER CASING for multi-cased wells OR LINER if a lica e
Lot b O l Well ( It 1 `1 1 n Q yl �00 ft. TO 1 ft, D /M'25 in. THI r ESS MATE C
Company Name V Y
^ +� /��/�r^/�-� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:1tilaO�t=IQ03 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) tt. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. r r
Non-Water Supply Well: It. / _
nd
Monitoring QRecovery ft. ft. `
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remcdiation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTraeer 20.DRILLING LOG attach additional sheets if necessary)
R _ FROM TO DESCRIPTION(color,hardness,soitfrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 1 ft.
4.Date Well(s)Completed: Well ID QQ02jfYY5/nlS� IlR
P5a.`Welll Locati�o�nA
u1l l 11
1 L4-Y V l ft. ft.
Facility/Owner Name
Facility ID#(if applicable)
�EYS1f1P5 t-t4R fVUrp [l�C. a$AbCo
Physical Address,City,and Zip ' ft. ft.
UP C� �{KG 10p,&W7&pq= 21.REMARKS
County L Parcel Identification No.(PIN)I,IJV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
y� N W 2� — —
6.Is(are)the well(s) Permanent or Temporary Si ature of Certified Well Contractor ate
0
By 'gning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or No w' ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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: 1 SUBMITTAL INSTRUCTIONS
^�
9.Total well depth below land surface: 3 P-0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Le (in.) 24b.For Iniection 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: /-k l n 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
1
13a.Yield(gpm) 14 Method of test: 1 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
13b.Disinfection type: ea[ek Amount'(30 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016