GW1-2022-03450_Well Construction - GW1_20220322

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' WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:.
1.Well Contractor
/Information:
14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
-- ft. ft.
l,jCWG 4�25-fr fr. tc
NC Well Contractor Certification Number 15.OUTER CASING for mulfi cased wells OR LINER if.a licablit
Cascade Drilling, LP FROM TO DIAMETER 1 THICKNESS MATERIAL
It. ft.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 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): fr. ft. in.
17:`SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 fr. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in
Industrial/Commercial Residential Water Supply(shared) IS.'GROUT
_;hTl ation FROM- TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring _,Recovery fr. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
SAND/GRAVEL PACK(ifsprilicalile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft
:]Geothermal(Closed Loop) Tracer 20.'DRILLING LOG'attach'additionalisheets'ifnecessi
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilfrock type,Zrain sae etc.
It. ft.
4.Date Well(s)Completed: Well ID# It. ft.
5a.Well Location: fr. ft.
U
Facility/Owner Name Facility ID#(i£applicable) @. ft.
ago 7r.,;efr 'Rd AA� LC old NG fL ft.
Physical Address,City,and Zip ft. ft F—f'^', r^
21 REMARKS n.
B rV ItSwr[Ic.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one Iat/long is sufficient) 22.Certification CW(
6.Is(are)the well(s)13Permanent or 13Temporary
Signature of Certified Well Contractor Date +�
By signing 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 MNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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 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 I GW-I 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: t (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli erem(example-3 a 00'and 1@I00') construction to the following:
t
10.Static water level below top of casing: q-(o (ft.) Division of Water Resources,Information Processing Unit,
if ater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
tr
11.Borehole diameter: (in.) 24b.For Iniection 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: .Sell f e- 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: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. F
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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