GW1-2022-04016_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform th)
I-p t Nib 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name ft. Z.5©ft. ! /s 9
aa6� 1 6 ft. 460 ft. 30
NC Well Contractor CertiticntZ
' 15.OUTER CASING for multi-cased Vreils OR LINER if lleable
t FROM TO DIAMETER THICKNESS MATERIAL
Q Z �Ulfl © ft. 1 ft. In. G
Company Name -
�� - ^� 16.INNER CASING OR TUdiIN (geothermal doseddoo
2.Well Construction Permit#: CJI FROM I To 1 21A6t TEft THICIams MATERIAL
List all applicable tivell carrsti'uctlon permits(i.e.UIC,County•,State,Variance,etc.) 0 ft 5 ft !n.
3.Well Use(check well use): ft. it, Ira
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural Municipal/Public it. ft. In
Geothermal(Heating/Cooling Supply) UResidential Water Supply(single) tt. ft. in.
Industrial/Commercial. Dkesidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERI EMPLACEM ErHOD b AMOUNT
11
Non-Water Supply Well: n' y tt ��'� 44
Monitoring Recovery ft. ft GCN��4
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK UcaPile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATFUTAL EMPLACENIF'N METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional.sheets if necessary)
Geothermal(Heating/CoolingReturn) � Other(explain under#21 Remarks) Toft.
TO DESCRHM N rotor,hardnen,sWitrack in size,etc)
to tt4.Date Well(s)Completed: - J o-UWel1ID# tt' C11So.Well Location: %5(X.61 b fFacilitytj3 ner Name +�- Facility tD##(ifapplicable) R' a
1113 q'1Vt0A 1 �� ft. ft. PR 6
PhysicalzAd�d6s,City,aah Zip ft.
21.REMARKS
County Parcel Identification No.(PIN) 1 l
5b.Latitude and longitude in degrees/lnlnutes/seconds or decimal degrees: G '
(ifwell field,one IaVlong is sufficient) 22.Certific lion:
N W
A "
6.Is(are)the well(s) . Permanent or Temporary Signature citified We Contractor Date
By signir g this form,I hereby certify that tire xrll(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constrrrcilon Standards and that a
ff ibis is a repair,fill out laaom:well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#t21 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: 1:
-� goo
INSTRUCTIONS
9.Total well depth below land surface: 1�o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: @L D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in•) 24b.For Infection Wells; in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Q 4�� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1.636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: b W 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: V 1 Amount: 1 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