GW1-2022-01544_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inf rmation:
Jb h P�a�t, 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. O m
Ap
ft. ft.
NC Well Contractor Certi cation Number 15.OUTER CASING formulti-cased.wells ORLINER 1'a doable
r FROM TO DL411f TER THICKNESS MAT L
V-Q� t ( � C� su ft. /�q ft. in. ' D Q
Company Name 6
- 1 16.INNER CASING OR TUBING(geothermal closedrloo
2.Well Construction Permit#: d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State,Varid e,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FROM REF. TO DIAMETER SLOT SITE THICKNESS MATERIAL
-)Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT I.
[Geotbermal
on FROM TO MATE [AL EMPLACEMENT OD&AMOUNT
ter Supply Well: o ft. 2 0 ft- n n i r
ring Recovery ft. ft
Well: ft. ft.
r Recharge QGmundwater Remediation
19:.SANDIGRAVELPACK if" licable
r Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test E)Stormwater Drainageftmental Technology Subsidence Controlrmal(Closed Loop) Tracer 20.DRILLING LOG attach additionaliheetsSfliecessarmal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRH'TION rniar,hardness,soiUrack a rain site eta)
ft. ft. '4
4.Date Well(s)Completed:la , y^� Well ID# it. 3oa n' rd A f e, K-QG IV,
ft. ft.
5a.Well Location:
SAM S a I V I h �` it. ft. M. IV
-i 9
Facility/Owner Name ( Facility ID#(if applicable) ft.
q
O I V I,/ (16 U(i( h Ia�� ft. ft. J01. Lr
Physical Address,City,and Zip ft. ft. J nr^ rtr i 1?i�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
N w PDX,
6.Is(are)the well(s) permanent or Temporary Signature red Wcll ntractor Date
By si i this form,1 hereby certify that the urfl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or [dNo with;A 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 and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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
construct iPit,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: 3,D (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi'fjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 0 (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: (in.) 24b.For Infection 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
(Le Well construction method: a w TO construction to the following:
(Le auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: j t'r 1636 Mail Service center,Raleigh,NC 27699-1636
13a.Yield(gP m) �'' Method of test: bJ8"" 24c.For Water Supply&Injection Wells: In addition to sending the form to
I_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Z. 'U 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