GW1-2022-01690_Well Construction - GW1_20220217

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 77
1.Well Contractor I;nfformation: p
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
R �(� p('
i-Ii ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
c p �i r 9 PP�� FROM TO DIAMETER THICKNESS MATERIAL
LL�� 1 I 1���C'I n� ft. k� 0 ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1e.UIC,County,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
-Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. sit. CA
Monitoring QRecovery
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology n Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,wil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID# t ft. l ft. c
Sa..IJ Well Location: ft.
ra r �1�L\C l�9 1p— ft. ft.
Pt
Faacii�lity/Owner Name Facility ID#(if applicable) � ft. ft.
Ynlcl? (Hilt 'Ra t \gesyiN , !V�- 09 ft' ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2.Certification:
N W ( 9� � I WILILY tom,
6.Is(are)the well(s) Permanent or Temporary Si ature of Certified Well Contractor Date
By gning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes orNo wit 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information]nd,xplain the nature of the Y 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:
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
a
9.Total well depth below land surface: 'abe-p -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: �{}®U (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 Iniection Wells: In addition to sending the form to the address in 24a
I� c above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.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
13a.Yield(gpm) Method of test: 1 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: 61 Amount: completion of well construction to the county health department of the county
where constructed.
t:n r'W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016