GW1-2022-03958_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only: Print Form
1.Well Contractor Information:
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NDAI r ft. ft.
NC Well Contractor Certification Number
`- 15.OUTER CASING for multi.cased wells OR LINER if a licable
R C FR M TO DIAMETER THICKNESS MATERIAL
�r ft. I c at ft. a5 in. L
Company Name ( / `1
y� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS 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 I THICKNESS I MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. is
hldustriaUCommercial Residential Water Supply(shared) 88.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery
Injection Well: I
ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rl Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets K necessary)
NFR M TO DESCRIPTION(color,hardness,saillrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft t ft.
4.Date Well(s)Completed:Ail l a—o[ot Well ID#0 0` 1 ft.
ft.(L!„ Q
34
Sa.Well Location: I ft.(
ft. ft.
Facility/Owner Name r Facility
,ID#r(if applicable) ft. ft�.M �� �� 1't'�1��Y t�I L N� ft. ft.
Phyf icai Address,City,and Zip �— ft. ft.
5401-QUY66 ,3 4CQ 21. MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary a of Certified Well Contractor Date
Ow'B3,
ping this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes orpnexplain
No 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information the nature of the copy f this record 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j (ft.)
6 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths y different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: qD (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: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
r(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: A6z 24c.I Por Water Supply&Injection Wells: In addition to sending the form to
{ 7 the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: L Amount: �() comp etion of well construction to the county health department of the county
wher constructed.
Form GW-I North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016