GW1-2022-03567_Well Construction - GW1_20220328

Print Form
WELL CONSTRUCTION RECORD(GW-1) r
r Internal Use Only:
1.Weil
\gd Contractor Information: � � f
g 6 t` Qn1 aJ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� (T�/�
NC-We- T3&3
NC Well Contractor Certification Number �j 15.OUTER CASING for multi-eased wells OR LINER if a livable
��`1 1 n Q n ]FROM TO DIAMETER THICKNESS MATERIAL
© ft. I ft. �in. t1 yC_
Company Name t/
40
16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. rt. in.
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
IIrI ation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. r ft.
Monitoring ®Recovery ft. rt.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology n Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I m TO DESCRI TION(color,hardness,soiVrock e, rain size,etc.)
^� ft. I rt.
Wej AL)
4.Date Well(s)Completed:_016_O'txWell ID# I ft. t ft.
ft. ft.
Z P 1 n
5a.Well Location:
CAy ft. ft.
M l
Facility/OwnerName t_64� 21 Facility ID#(if applicable) ft. ft.
014ie_lJ onP_ 1M T)'rmt rik uiyef 44u Vt le- 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:
(if well field,one lat/long is sufficient) 22.Certification: qq
N W A.JAQAA
6.Is(are)the well(s) Permanent or 13Temporary ture 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 wit SA 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 explain the nature of the co f this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23. ite 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 cons ction details. You may also attach additional pages if necessary.
1 drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 V W (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') cons ruction to the following:
^ t
10.Static water level below top of casing: [ (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: Q in.( ) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,A r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:A 1�z l' ( () cons ction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
ivision or Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c
13a.Yield(gpm) l�b Method of test: I 24c.For Water Supply&Iniection Wells: In addition to sending the form to
theaddress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type.' P01 e6Amount: �0 completion of well construction to the county health department of the.county
where constructed.
Form GW-1 North Carolina Department of Environmental Quility-Division of Water Resources Revised 2-22-2016