GW1-2022-03568_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD (GW-1) or Internal Use Only: Print Form
1.Well Contractor Information:
cs� -
IkMS �(���` `a�d�ti.In 4.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a livable
a ; '� a FROM TO DIAMETER THICKNESS MATERIAL
t ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-lot
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i .SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
—thriiiation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring QRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 10,SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test [DStormwater Drainage
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) nTracer 201 DRILLING LOG attach additional sheets if necessary)
OM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Coolin
g Return) -- Other(explain under#21 Remarks) Im ft. It.
a
Lk to
4.Date Well(s)Completed: 'OsC1 Well ID#
ft. ft.
5a.Well Location:
ft. ft.
Facility/ ner Name Facility
s ID#(if applicable)
NA mi' L me' ft. ft.
t2 b Q®q rt. ft.
Physical Address,City,and Zip ft. ft.
21. MARKS
c
County Parcel Identification No.(PIN)
. _ e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22. ertifica
N W d
6.Is(are)the well(s) Permanent or Temporary Si rture of Certified Well Contractor -Date
ry
By i$ning this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No wt :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 informationOdxplain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 SUB v1ITTAL INSTRUCTIONS
9.Total well depth below land surface: 4nbt(), -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-�33@200'and 2@100') consl ruction to the following:
10.Static water level below top of casing: ��JC� (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: Lp (in.) 24b. or Injection Wells: In addition to sending the form to the address in 24a
c abov ,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �� cons ction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
D 'sion 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: o® 24c. or Water Sunvlv&Injection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 400 Amount: comp etion of well construction to the county health department of the county
wher constructed.
Form GW-1 North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016