GW1-2022-01630_Well Construction - GW1_20220125

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
�I.Well Contractor Information:
AI"1ES D An 1 G W l 1501) 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
LNtc l—
NC Well Contractor Certification Number 15.OUTER CASING for multi-cssed wells OR LINER if a licable
` p c FROM TO DIAMETER THICKNESS MATERIAL
` 1 V ft. 1 ft. Qs in. V off
Company Name
16.INNER CA SING OR TUBING(peother al closed-loop)
2.Well Construction Permit#: 60 /� FROM TO DIAMETER 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.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) B
Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft.
Monitoring ®Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets K necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating(Coolin Return) Other(explain under#21 Remarks) it. 1 ft.
4.Date Well(s)Completed: Well ID#d9(— I in 1 ft. f ft.
ft. ft. c
a— Well ocation: 78
fii �K -Kpmlm eizClinex
Facility/Owner Name 1 1,fit, `p v Facility me—
(if applicagble))] ft. ft.
(� �� 5� �[lkoeo 'Ill r— mec � O`7bq ft. ft.
Physical Address,City,and Zip
/ (;�, ft. ft.
r �1M�� P 21.REMARKS
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 Certification:
N W Jbk412 7cjw�i A,Q, 1 A I �' �F—c
6.Is(are)the well(s) Permanent or Temporary Si ture of Certified Well Contractor Date
By s ing 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 No with 5A 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 n explain the nature of the copy f 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: I SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: ;:Mr�p (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Cal
(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: Q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
A t�, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:y i construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) r
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: Wk1 24c.For Water Supply&Iniection 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: h1l� W
tJ ?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