GW1-2022-01587_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 3 000 ft. M
NC Well Contractor Certification Number i5.OUTER.CASTING for multi d Its OR LRNER feeble
�• FROM TO DIAMETER THICKNESS MATERIAL
ft. L4
ft. I to in. V v
Company Name
Ifs INNER CAS OR TUBING leotbermalchise0gap
2.Well Construction Permit#: �// •_ U ( � I 1 — �I l FROM TO I DIAMETER THICKNESS IMATERIAL
List all applicable well construction permits C.e.UIC,County,State,Varfah etc. — it ft. I in.
3.Well Use(check well use): ft. ft
Water Supply Well: FROM SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
Industrial/Commercial E)Residential Water Supply(shared) t&GROUT
kiriIlion FROM I TO MATERIAL' EMPLACEMENT METHOD d:AMOUNT
Non-Water Supply Well: (� ft' ft'
. ..Monitoring DRecovery ft ft.
Injection Well: ft.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK if licable
Aquifer Storage and Recovery []Salinity Barrier FROM TO I MATERIAL. EMPLACEMENT METHOD
Aquifer Test JDStormwater Drainage ft• ft.
Experimental Technology ®)Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG; attach additional sheets ff.
Geothermal(HeatingtCooling Return) Other(explain,under#21 Remarks) FROM To DESCRnmoN valor,uardoess,soil/rack tim grafn sly,etc.
tj al
4.Date Well(s)Completed: Well ID# LLB 3 b ft, ft.
IL
dJJ ft. «.
Sa.Well Location:
Q n � r ft. ft.
FactlityfClwner,Name Facility ID#(if applicable)
533 r `� ft. ft
___�_
Physical Address,City,and Zip —T (�( Q[ ft• ft• „-,.;r n�,;•a�l�
1-]1 1✓ 21.REMARKS i :'
L�(cam ,.: Gv �
county Panel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W PU/
6.Is(are)the wells) ,Permanent or 13Temporary
Signature of Cerd Well Con Date
By signing this fill",I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 6No with 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 and explain the nature of the copy of thus 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:
You may use the back of this page to provide additional well site details of well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1_ SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: 10V (R-) 24a. For All Wells: Submit this; form within 30 days of completion of well
For multiple wells list all depths ifdf jferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 276994617
t
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
12,Well construction method: f a FL( construction to the following:
(Ic.auger,rotary.cable,direct push,etc.
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water SuDnly&Infectloir Well: 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: Z completion of well construction to the county health department of the county
where constructed.
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Farm GW-1 North Carolina Department of Environmentat Quality-Division of Water Resources Revised 2-22-2016