GW1-2022-03460_Well Construction - GW1_20220323

WELL CONSTRUCTION RECORD(GW 1) Print Form
o Internal Use Only:
I.Well Contractor Information:
----���,�,��-I� ATER 20NES
Well Contractor Name M TO DESCRIPTION
N C (
bf e- 03 ft. ft.
NC Well Contractor Certification Number ft.
ft.
1 . UTER CASING for multi-cased wells OR LINER !f a 6cable
F M TO DIAMETER THICKNESS MATERIAL
Company Name ft• sft• 7 m. ; DM `fr
1 . NNER CASING OR TUBING eothermal closed--loo Y
2.Well Construction Permit#: M TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits f.e.U1C,County,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1 . CREEN
Agricultural F M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18 ROUT
hri ation TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. s ft. n
Monitoring Recovery ft. ft.
My
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery19 AND/GRAVEL PACK if applicable)
Salinity Barrier FR TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®Tracer 20.' RILLING LOG attach additional sheets Knecessa
Geothermal(Aeating/Cooling Return) Other(explain under#21 Remarks) To DESCRIPTION(color,hardness,soil/rock tv e, rain size,etc.)
u *� ft.
4.Date Well(s)Completed:' -OrO� Well ID# ft. ITtJ lFt. �.�I
cis
5a.Well Location:AFacili
nffi n ft.ty/O r N—amen L1— Facility ID#(if applicable)
t;W JP —Mr,- [-Fero a6 !nSKltte• ItL ft. ft.
P ysical Address,City,and ZipSJ rft. ft.
21.I MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertitication•
N W e
6.Is(are)the well(s)FQ Permanent or Temporary i ure of Certified Well Contractor Date
By i ning 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 wir I A 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 c y this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.S to diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay 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 consl uction details. You may also attach additional pages if necessary.
drilled:
-t pp,,,,f a s SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: plc (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
list all depths ifdifferent(example-3@200'and 2@100')
For multiple wells const ction to the following:
Ij
Q�� t
f 10.Static water level below top of casing: l)() (ft.) Division of Water Resources,Information Processing Unit,
water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LD (in.) 24b.tor Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: abov also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) cons etion to the following:
Df 'Sion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
AA 7 i
13a.Yield(gpm) Method of test: ik I�\ 24c. For Water Sunnlv&Injection Wells: In addition to sending the form to
the dresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:—(36 comi 1-tion of well construction to the county health department of the county
whem constructed.
Form GW-1 North Carolina Department of Environmental Qugl ty-Division of Water Resources Revised 2-22-2016