GW1-2022-01625_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
�-3wCS5 D'An t o U V J:5C)1) 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
RM L 43 * ft. 4fftt
NC Well Contractor Certification Number ft. --
15.OUTER CASING for multi cased wells OR LINER If a livable
y1z �n 1� FROM TO DIAMETER THICKNESS MATERIAL
ompa L 1 I la 0 ft. h7 i ft. 1 ;Win. D P YC
Company Name � l
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I 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) ft. ft.
Industrial/Commercial flResidential Water Supply(shared) 1S.GROUT
71 Irrigation FROM TO ATERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. l ft. Q _bagw
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sell/rack type,grain size,etc.)
0 ft. 1 ft.
4.Date Well(s)Completed:l aL2E-12L Well ID# i ft• LD 1 ft. —5rptzo z5 e
5a.Well Location:
ft. ft.
Facility/Owner ame Facility ID#(if applicable)
ft. ft.
Physical Address,City,and Zip ft. ft.
cyZUI,e:e— 21.RE,MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W t ^
,�,t o��—r�I
6.Is(are)the well(s)iY(Permanent or Temporary Si tore of Certified Well Contractor Date
TS B signing 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 ith 15A 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 40explain 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:
S.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- (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) 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: j Q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n , above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ill_I R I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Iujection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test:' `�� 24c.For Water Suauly&Injection Wells: In addition to sending the form to
`` -2� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �l Amount: i36 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