GW1-2022-01935_Well Construction - GW1_20220224

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: p
b L 2'� � I U fN � ��p Q, 19:W ATER ZONES l
Well Contractor Name FROM TO DESCRIPTION
� ' ft �f ft.
. 4 ft
os_
NC Well Contractor Certification Number 15.OUTER:CASING:for maitt-cased wells OR LINER,K a' licabl
/� (� FROM TO DIAMETER THICKNESS MATERIAL
Gi r""-X &a I L V�=� Z I/l ln►f 1 A. O ft Q ft. in. �/C
Company Name 1b:INNER CASING OR`TUN NG eothermal closed-loop!
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Varil,`r,etc.) ft ft. in.
3.Well Use(check well use): ft ft in-
Water-tSupply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft in.
industrial/Commercial OResidential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD$AMOUNT
Non-Water Supply Well: n ,a 0`„, _ A e— r4 ,
Monitoring Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19.`SANDIGRAVEL PACK'if a licable_
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPtACEmENTMETHOD
Aquifer Test E)Stormwater Drainage H• ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. KILLING LOG tattach additloiial sheets:if nee
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRiMON eotor,bmidness saturock a )n ' etc.)
m
p ft. 0 ft. Gj� np
4.Date Well(s)Completed: ZQ "ZZ Well ID# ft 0 ft S 4 h,d
Sa.Well Location: tt. ft. ra l C
h J I ev k i1 1 ftft.. ft.
Facility/Owner Name Facility ID#(if applicable)
' $__
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Physical Address,City,and Zip
ft, ft.
Iru h l 21,REMARKS
County Parcel Identification No.(PIN) �ul �lu
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the wells) Permanent or Temporary Signature ofC 'fled Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No with 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 and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks,tertian 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
9.Total well depth below land surface: (ft-) 242. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths If di&rent(example-3C200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 7-0 (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
r Y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4 1 r (AA 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C6ter,Raleigh,NC 27699-1636
13s.Yield(gpm) - Method of test: loin 24c.For Water SuDDIv&Iniection'Wells: In addition to sending the form to
11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h 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