GW1-2022-04004_Well Construction - GW1_20220426

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WELL CONSTRUCTION RECORD (GW-1) r
Internal Use Only:
1.Well Contractor Information:
� km En `ox) el W f l5o n 14. ATER ZONES
Well Contractor Name Flit M TO DESCRIPTION
A��+C�/�/� y � 7 fit. ft.
I V,lrll�l C- L4VC)5 ft. fit.
NC `W`Well Contractor Certification
Number y� /� 15. UTER CASING for multi cased wens OR LINER(if a licable
10 S I�( IU L6l'-� 1`11 V1 I 1 1 Q 'I n C. FR M fit. TO I it. DIAMETER In. THICKNESS MATERIAL
Company Name 3� r PVC,
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FRC M TO DIAMETER 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.SCREENFRC M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. I in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial AResidential Water Supply(shared) 18. ROUT
hTi ation FRC M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1
Monitoring Recovery ft. ft.
Injection Well:
fit. fit.
Aquifer Recharge ®Groundwater Remediation
19. AND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FRC M TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) Tftt*
To DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
t4.Date Well(s)Completed: Well ID#
0 At5a.Well Location: *l' ft.w �� V fit.
F�aci�lity//O'wnerName Facility ID#(ifapplicable) ft. ft.
_ t1g_AQI� .MGmhc� M C�lT fit. fit.
Physical Address,City,and Zip ft. ft.
(( `
l�l si-z `` -e. 21. WMARKS
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:
c
N W e
L4-r3 -aD
6.Is(are)the well(s)gXlPermanent or Temporary J��"5A
ture of Certified Well Contractor Date
TTTT Wing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r1Yes or No 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 d explain 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. 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
construe Ion,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells cons ruction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: llJ( (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) cons ruction to the following:
^^AA /
10.Static water level below top of casing: r 6 (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: (in.) 24b.For Iniection Wells: hi addition to sending the form to the address in 24a
,A a abov ,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A)' R r l42 V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
11 ivision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
0
13a.Yield(gpm) Method of test: 2 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: Pfffir.6 Amount: C Y) completion of well construction to the county health department of the county
whet a constructed.
Form GW-I North Carolina Department of Environmental Qu ility-Division of Water Resources Revised 2-22-2016