GW1-2022-03754_Well Construction - GW1_20220406

WELL CONSTRUCTION RECORD(GW 1) For Internal Use only: Print Form
1.Well Contractor Information:
W�-7-5 D—Y)E:L 14.WATER ZONES
tic—we,
Contractor Name FROM TO DESCRIPTION
l V�C l/1[l "fC� � ft. ft.
ft. ft.
NC Well Contractor Certification Number
�Q 15.OUTER CASING for multi cased wells OR LINER ijilekable
FROM TO DIAMETER THICKNESS
1 { ft. t ft. f., in. `..'Company Name �� 16.INNER CASING OR TUBING eothermal closed-loo2.Well Construction Permit#: pL P17.SCREEN
TO DIAMETER THICKNESS
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well:cultural TO DIAMEMunicipaUPublic ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial oResidential Water Supply(shared)
1S.GROUT
Non-Water NhTigationtr Supply Well: ft.FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. _
Monitoring DRecovery ft. ft. v
Injection Well:
A uifer Recharge ft. ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if applicable)
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCR TION(color,hardness,soil/rock type, rain size,etc.)
ft. t ft.
4.Date Well(s)Completed:L�-oy Well ID#W=[= I ft. t ft.
5a.Well Location: ft. 6 ft.
Lr� ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical
Address,City,and Zip I
/I (� ft. ft.
L\EE fl b jM�(F/ 1_ (� 21.REMARKS
County L Parcel Identification No.(PIN))
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
N
r15A
� -
6.Is(are)the well(s) Permanent or Temporary ified Well Contractor ate
orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information d plain the nature ofthed 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
ff,^,t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�,p0 W (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,/�erent(example-3@200'and 2@100)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: K above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 SuDDIy&Iniection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016