GW1-2022-04017_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Ar\ic,& lM s 14.WATER ZONES
FROM TO DESCRIPTION
Well Contract r Name A,�
�� �O A it. S ft. IS '•l
ft. ft.
NC Well Contractor Certification Number r 15.OUTER CASING for multi-cased wells ORLINF.R<1f ileable
rd O 'I n I r p. FROM TO DIAMETER THICKNFSS I MATERIAL
Company Name
` .16.INNER CASING OR TUBING mthermal closed-loa
2.Well Construction Permit#: G1W 0 �lO ' a I FROM To DIAMETER THICKNE65 MATERIAL
List all applicable imll construction permits ri.e.UIC,County.State,Variance.eta) [t ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su 17.SCREEN
Supply Well: FROM TO I DIAMETER I SLOTSrM TIUCKNEM MATERIAL
Agricultural unicipal/Public it. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R• ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
hri ation FROM TO MATERIAL EMPLACEMENT L METHOD&AMOUNT
Non-Water Supply Well: Q B' 20 tt w h i t
hk
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Itcable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O5tormwater Drainage R n'
Experimental Technology OSubsidence Control il• il•
Geothermal(Closed Loop) OTracer 20.DRILLING LOG fattich additional sheets if necess .
FROM TO DUCRUMON(color,hardam,% t1rock tMe.grain size,etc.
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks)
4.Date Well(s)Completed: 3 43-a4 Well III# rs ft' 0 o fr' G k
5a.Well Location: ft ft.
kvan
Facility/ ner Name Facility ID#(if applicable)
tt ft. J
Physical Address,City,and Zip R'
1151/ 0,10 21.REMARKS
J'�•-,:iFi,i ll.a'!f it V'.r •.9:...,+ :,I':I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/long is sufticicat) 22. ertilication:
N W S— �3-ZZ
6.Is(are)the well(®) Permanent or Temporary Signa of C ficd Weil Contractor Date
By signing this farm,I hereby certify that the uvll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 6No with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ijthis is a repair,frll out known well construction!rllormation and explain the nature of the cop)-ojdiis record has been provided to the well owner.
repair under#21 remarks section or on lire back of this form.
23.Site diagram or additional well details:
S.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
constructipn,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
i drilled: J a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I y y —(ft*) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example 3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (fr•) 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 Infection Wells: In addition to sending the form to the address in 24a
a l r r6��� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I '.) 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 1 Method of test: 1� a 24c.For Water Supply&Infection 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: Amount: Z I 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