GW1-2022-03750_Well Construction - GW1_20220404

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CORD(GW-1� For Internal Use Only:
WELL CONSTRUCTION RE
1.Well Contractor Information:
14.WATER ZONES DESCRIPTION
Well Contractor Name Ft.FROM TO ft.
4 303 ft. ft.
a licable
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. t as in. e1
I 1G
Company Name 'r 16.INNER CASING OR TUBING thermal closed-►oo
dbn
��/' tY y,h'Y FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#'. ` f [ ft. ft• 1O'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. in
ft.
3.Well Use(check well use): 17• CREEN
Water Supply Well: TO SLOT SITE THICKNESS MATERiAi.
FRAM DIAMETER
i.��tlMunicipal/Public ft. ft. in.
Agricultural LI
Geothermal(Heating/Cooling Supply)
Residential Water Supply(single) ft• ft. i°
1ndustrial/Commercial3 DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
hri ation ft. a ft.
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well: Ft' rt.
Aquifer Recharge Groundwater Remediation 19,SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier
FROM TO MATERIAL PLACEMENT METHOD
ft. ft.
Aquifer Test [3Stormwater Drainage
rl Subsidence Control
Experimental Technology
ft. ft.
20.DRILLING LOG attach additional sheets if necessar
Geothermal(Closed Loop) Tracer FROM TO DESCRIPTION(color,hardness,soiUrock e, rain sue etc.)
Geothermal(Heating'Cooling Retum) Other(explain under#21 Remarks) g, F ft.
��ryry
4.Date Well(s)Completedr�C�L-oks Well ID#
ft. ft.
�5a.Well Location:
t_ ® ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
ft
��_��� . ft.
Physical Address,City,and Zip 21.REMARKS
cCnal?�P a,i�Q�S 91
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient)
a
N W P'
Date
Si ture of Certified Well Contractor
6.Is(are)the well(s) Permanent or Temporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
w h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Yes or No py of this record has been provided to the well owner.
if this is a repair,fill out known well construction information an explain the nature of the
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 details. You may also attach additional pages if necessary.
construcjton,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:1
i
9.Total well depth below land surface: (ft•) 24a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: �Y®1 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: �� (in.) 24b.For Iniec addition to sending the form Co the address in 24a
s above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I d� ® construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
=(gpM) 01
Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: s 24c.For Water 5unDly&Yniection Wells: In addition to sending the form to
the addresses) above, also snbmrt oney of this form within 30 days of
Amount: c9� completion of well construction to thecounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016