GW1-2022-04046_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Tr)o' Rob!g, 14.WATER'ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
NC Well Contractor Certification Number l5.OUTER;CASING for'muiti-eased:wells OR LINER if a licable
j FROM I TO DIAMETER THICKNESS MATERIAL
ii 6' 1 ` ft. ft. In.
Company Name 'a16.INNER CA OR TURING:f eotherrual closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. to ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN(..
pp y FROM TO DIAMETER SLOT SiZE I THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) r Residential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) 18;GROUT-
hTl orlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well:
_ ft. ft.
Aquifer Recharge []Groundwater Remediation
14.SAND/GRAVEL,;PACK if a"licable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. it.
- Experimental Technology []Subsidence Control ft. ft.
Geothemial(Closed Loop) []Tracer 20.DIULLiNG'LOG attach:additional sheets ifnecessary
Geothermal(Heating/Cooling Return) Other(explain under#21.Remarks) FROM TO DESCRrMON color,kardums,soilfrock type,grain size,etc.
a.
4.Date Well(s)Completed: L Well ID# ft. o
ft. ft.
5s/.,Well Location: 2- 1>h
Faciility/jO�wnerName
a Facility ID#(if applicable) ft. ft.
I I ( 1,L kwy ft. ft.
—�
Physical Address,City,and Zip R' if
2L RE LARKS `r4+ .1 r :.(ii•,y .<,,. r th'.1 i� "
County Parcel identification No.(PIN) thstalled �T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t-0
(if well field,one lattlong is sufficient) 22.Certification:
N W0�� 4�� 3- 1q-12
6.Is(are)the well(s) Permanent or []Temporary Signature ot Certified Well Cmitra7etor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 1A with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out knoxm well construction information 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. hidicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: fl 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 wells list all depths if different(example-3@200'and 2@100D 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 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
r &d
12.Well construction method: a 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: 24c.For Water Supply&Iniection 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: T Amount: b 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