GW1-2022-04024_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractorinformation: _
cJ b h ['90 C• 14,WATER ZONES
FROM I TO I DESCRfF't'ION.
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER.CASING.for multt4ased:iwAs OR LINER s Ileabie
FROM TO DIAMETER THICKNESS MATERIAL
ra o le G ft. 101LL-In- f-_ v
Company Name f i{,.W(NER C11 11 G OR eotfierrital closed-loop).. ,
2.Well Constrac8on Permit#• FROM I TO ETER THICKNESS I MATERIAL
List all applicable xell constnrclion permits(i.e.WC,County,State.Variance,eta)
ft. ft. in.
3.Well Use(checkwell use);
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. it In.
Geothermal(Heating/Cooling Supply) EIResidentiai Water Supply(single) ft. ft
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d i t 6 ft. r Q
Monitoring Recovery ft• It.
Injectionwell; ft ft.
Aquifer Recharge [3Groundwater Remediation t9.SANDIGRAVEL P.ACIc f a 9rcable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage
mtpecimentai Technology Subsidence Control ft. il•
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional shedsif necess
FROM TO DESCRIPTION Co: le.grains Mu
Geothermal(Heatin ooling Return) nOther(explain under#21 Remarks 0 ft, to
4.bate Well(s)Completed: Well IID# too ti' alp R'
ft. ft.
Sa.Well Locatio
H'Vn�Vii<1��` tt.
Facility/Owner Name Facility 1D#(if applicable) ft.
G 5 o S a k�rs•�I�,��r,�G-t �f�w� a��D'T jAW
physical Address,City,and Zip
L21.RE �~
County Parcel Identification No.(PIN) a,,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w
6,Is(are)the well(s) Permanent or Temporary Signa o�Certified�cll Cotrtcactor Date
By signing this form,1 hereby cwrlify that the urll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or GNo Wilt 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Cansinrclian Standards and that a
If this is a repair,fill out known ivell construction h formation and explain the nature o(the copy of lids record has beenprovided to the well owner.
repair under#21 remarks section or on the back of thisforni. 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: f �1 SUBMITTAL INSTRUCTIONS
o
9.Total well depth below land surface; "Y D A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdiferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 0 (t't.) Division of Water Resources,Information Processing Unit,
If waster level is above cashig,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: Q i r rA Lt ne construction to the following:
(Le.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) 5 Method of test: D 24c.For Water Supply&Inlection 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: •k Amount: Z completion of well construction to the county health department of the county
where constructed.
Fora,GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016