GW1-2022-04020_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U LG ar•►S 14.WATER ZONES
r .
—� FROM TO DESCRIPTION
Well Contractor Name tt. 6 p ft. 2 j�
b
NC Well Contractor Certification Number .15.-OUTER CASING.formulti-cased welts OR LINER ifa livable
IUCra FROM TO M1fET DIAER HI TCKNESS MATERIAL
I C/ W C U ft. S'� ft. in. V G
Company Name �J 16:INNER CASING OR TUBING- eothermai closed-loo
2.Well Construction Permit#: r�W 0—W - FROM1i TO DIAM1iETER ITHICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State.Variance,ere)
ft. ft. in.
ft. ft. in.
3.WellUse(check well use):
17.SCREEN..
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural unicipaVPublic
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft. In
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL, EM1IPLACEMEN. THOD&AMOUNT
Non-Water Supply Well: 6 ft. ft. i^t YctU l
Monitoring Recovery ft. tt.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation t9:;SAND/GRAVEL PACK ifa livable}
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPr,ACEM1HiNT METHOD
Aquifer Test Dstonnwater Drainage ft. ft.
Experimental Technology EJ Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach adilitiaaal sheets.ifnecess . .
FROM TO DESCRIPTION color,hardness,soiVreck t3tiiS grain sim,etc.)
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) b ft. b
4.Date Well(s)Completed: �— Well ID# b ft. ob ft. t�U
ft. ft.
5a.Well Location:
�an�i�ert ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Qohe 'fj- 1 rj
Physical Address,City,and Zip ft. ft. 2 202
4 k C I (A a g 3 V 6 3 21.REMARKS
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.Ce lion: G
6.IS(are)the weIl(s) Permanent orTempo7No
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I or with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Constriction Standards and that a
If this is a repair,fill out knonvi ivell constriction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if diereni(example-3@200'and 1@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: (in.) 24b.For Iniection Wells: lniaddition to sending the form to the address in 24a
�f above,also submit one copy of this form within 30 days of completion of well
12,Well construction method: Q if, r o` g 1 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: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: '0 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: Amount: 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