GW1-2022-01590_Well Construction - GW1_20220120

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RUCTION RECORD GW-1 For Internal Use Only:
tractor Information:
k
C_- 14:WATER ZONES
FROM TO DESCRIPTION
->Well Contractor NameV ft. ft.
2 zf - p ft- 26 I ft,
NC Well Contractor Certification Number' 15.OUTER CASING for multi-cased wells)OR
LINER �f a licable
FROM Mt
TU DiETER In. THICKNESS CKNE MATERIAL
71 ft. /
Company Name tl- 16:INNER CASING OR TUBING Jgeothervtel dosed400
2.Well Construction Permit 4.6-0 O 1�/ 0 ✓ 0 2' FROM TO DIAMETER THICICNFSS MATERIAL
' fL ft. in.
List all applicable well construction permits(i.e.UIC,County,Sta Varib fc�,�etc„1
3.Well Use(check well use): �a �`Q � r 1J (- fL f t In.
17.SCREEN
Watef'Supply Well: FROM I TO DIAMETER I SLOT SIZE TMCIMESS MATERIAL
Agricultural DMunicipal/Pubiic tt. it ia.
Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single) f1, ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROU7•.
hri ation FROM TO MATERIAL EMPLACE MENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2 s fa n y to
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation 19.:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed.Loop) Tracer 20.DRILLINGLOG fattach additiogal sheets ffneeessa
FROM TO DESCRH'TION color,hardness soil/rock a in st etc,
Geothermal(Heating/Coolin Return) Other(explain under#21 Remarks) � ft, /� ft.
o 'L
4.Date Well(s)Completed: 12- 2,1 Well ID# ft. ft.
5a.Well Location:
ft. ft.
rV th e-
F„
Facility/Owner Name Facility ID#(if applicable) ft. ft. �n
�� 1 �Y 4.J ft. ft
Physical Address,City,and Zip
21.REAIARKS'
County Parcel Identification No.(PIN)
r t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)opermanent or Temporary ure fCertifie a Contractor,
By signing this form,I hereby certify that the it ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or �o with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knomi well construction information and explain the nature of the copy of this record has been provided to the well miner.,
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: 201) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/is list all depths if different(example-3C100'and 2@ 100D construction to the following:
10.Statle 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 Infection Wells: .In addition to sending the form to the address in 24a
above,also submit one copy oftthis form within 30 days of completion of well
12.Well construction method: ph construction to the following:
(Le.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
13s.Yield(gpm)_� Method of test: do �0 24c•For Water Suaniv.&Injection Wells: In addition to sending the form to
the For
above, also submit one copy of this form within 30 days of
13b.Disinfection type: _ Amount:_/, -o7- _ 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