GW1-2022-01492_Well Construction - GW1_20220126

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor
'Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
O ft. ' to ft.
2 y/3 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased ivelis OR LINER if a ticable
Terracon Consultants FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eothermarclosed-loo ' _
2.Well Construction Permit#: FROM I-TO I DIAMETER .1 THICKNESS.- I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL ft. in.
3.Well Use(check well use): tL ft. in.
Water Supply Well: 17.SCREEN
FROM TO .DIAMETER SLOT SIZE THICKNESS -MATERIAL
Agricultural 13Municipal/Public 9 dt. S o ft. 2 in. -0/0 s"4• 0 4-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in, l
IndustriaUCommercial Residential Water Supply(shared)
18.GROUT
71 irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D -ft- 3.6. ft. m/J W�hf- �/' to ?
x Monitoring EiRecovery L It- z tt.
Injection Well: v ! hen mode ll f !'Ylv/ �!
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
Aquifer Storage and Recovery 13 Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 3 ft. �-o fL 2 fQ y 2vll
Experimental Technology [3 Subsidence Control tt. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if.necessa
Geothermal(Heating/Cooling Return) Other.(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,min size etc.
t7 tL S ft. teal !f-� r
4.Date Well(s)Completed: I Z �7 Well ID# /�A '7 ft. tt. �� ��f G v !
a^•ft. 1 �. �
5a.-Wnell Location:(
Facility/Owner Name Facility ID#(if applicable) ft. ft.
It. tL
Physical Address- ,City,and Zip ft. ft.
o0/ P 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: -
3S-2 CO N -79 Sao 5 53 W 1i tl
6.Is(are)the weil(s) rmanent or Temporary Si tore of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Vo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I06� construction to the following:
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: . (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: Qu�l Pt� 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
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: 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