GW1-2022-01634_Well Construction - GW1_20220126

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
` 14.WATER ZONES - -
�r�ifl,�� FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC Well Contractor Certification Number 15.OUTER CASLYG(for multi cased wells OR LINER' a tieable
r FROM TO DIAMETER THICEVESS MATERIAL
* fL fL21
Company Name 16.INNER CASING ORTUBING(eothermatclosed400
FROM TO DL1!KETF:R THICKNESS X►Tc�I'
2.Well Construction Permit#: % in.
List all applicable well construction permits 6.e.UIt;County,State,Parlance,ere-)
fL $, in.
3.Well Use(check well use):
17.SCREEN-
Water Supply Well: FROM TO DIAMETER SIATSIZS THIQ WM- MATERIAI,
Agricultural 0MunicipaUPublic it fL in.
Geothermal(Hearinecooling Supply) residential Water Supply(single) fLEEJ 7d
2
Industrial/Commercial oResidential Water Supply(shared) 1&.GROUT
FROM TO MATERIAL gMPLACEME.IIT METHOD 8 AmoUNT
hri lion ,r, ft. i fL r
Non-Water Supply Well: R f
�Rccovcry ft. fL
Monitoring
Injection Well: d fL ft.
Aquifer Recharge Groundwater Reme 'eatian 19.8A.YD/GRAVEL PACIt rf a IiCaLle
t)Aquifer Storage and Recovery Salinity Barrier FROM 1 To MATERIAL F-Nm&CEMMF-NTMETHOD
Aquifer Test
Stormwater Drainage fr' tr
Experimental Technology oSubsidenee Control D R
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach addltianaf sheets if neces
P
FROM To DESCRIPTION{cobs 6ardaeu,soiVroeL 4 n size etc?
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) fL ft.
fL
4.Date Wells)Completed:
Weil ID# F
ft. ft
5a.Well Location: fL ft
f '��f1 ft. iL -
,ae;tity wnerNamey/ F�aefL�ll�iytyIDt�lC(i�fapplicable}^ ,
fL
ft
Physical Address,City,and Zip
21.REMARKS
County Parcel Ideotificatioallo.(PIN)
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
W i QA
rue of Certified We 1 Contractor Date
6.Is(are)the well Permanent or Temporary ;X\
By si�rring this farm,I ltErebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an Misting well: Yes or Na withlrl5A NCAC 02C.0100 or I5A NCAC OZC.020t)Well Construction Standards and that a
/flhis is a repair,fitt out knorsrt well construction information a explain the nature oft
he
°cepy ofthis record has been provided to the well owner.
repair under w21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop:Geothermal Wells having the same You may use the back this page to provide additional well site details of well
construction details. Youu may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
SUBMITTAL INSTRUCTIONS
drilled-
within_,t _(Ft) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: t e $a
For multiple wells list art depths ifdifferent(e sump[a-3@1-00 and 2Q1001 construction to the following:
10.Static water level below top of casing: 4 6 v (fL) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail service Center,Raleigh,NC 27699-1617
IL Borehole diameter fT_(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: i l t A — construction to the following:
4.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
c
13a.Yield(gpm) Method of test I 24c.For Water Supply&Infection Webs: In addition to sending the orm to
the address(es) above, also submit one copy of this form within 30 days of
s') Amou°t: t�fN completion of well construction to the county health department of the county
13b.Disinfection type: where constructed-