GW1-2022-04023_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Tnternal Use Only:
1.Well Contractor Friffo�r„ ation:
14.'WATEIt.ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Nu her -f&OUTER CASING fon:multl iil v is OR LINER'if a licable
FROM T DIAMETER THICKNESS MATERIAL�MpU 111 t ft. ft. in.
Company Name
y t ) � r 16.INNER CASING'OR TUBING `cothermal closed+loo .
2.Well Construction Permit#: (a UJ (� I FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. im
Water Supply Well: 17.SCREEK
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. !
Industrial/Comtnercial E311csidential Water Supply(shared) 18.GROUT. .
Irri ation FROM TO MATERIAL EMPLACEMENT WTHOD&AMOUNT
Non-Water Supply Well: ft. 110 ft. 10
Monitoring EIRecovery ft. ft.
Injection Weli: ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL RACK(ff a Ilcable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL. I EMPLACEMENT METHOD !
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG'atfach additliinal sheets i£decessarY
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks)J FROM TO DESCRIPTION color hardness,soillrock type ain sim etc)
ft. ft. ��•�
4.Date Well(s)Completed: 'i 'I—Well ID# O ft. ® ft n ,
5a.Well tLocation: / ©/D
r U �17 )A ft. ft. _
Facility/O% Name Facility 1D#(if applicable) ft. ft
heirs et, 2-7616
Physical Address,City,and Zip
/.t 21.REMARKS
e-
Count Parcel Identification No.(PIN) ru ti n
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
/ N W J'm 3­ 21 ­2-2-
6.Is(are)the wells) Permanent or DTempoWN,
Signatu of Certified Well Contractor Date
By signing this form,I hereby certify that the is a I(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction h formation and explain the nature of the copy of 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:) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160 (fL) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths if different(example- @200'and 2@I001 construction to the following:
10.Static water level below top of casing: (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 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:_ g 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 27699-1636
13a.Yield(gpm) Method of test: la W 24c.For Water Supply&Injection Wells: In addition to sending the form to
g� )� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: f 1 r r Amount: 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