GW1-2022-04047_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
L Well Contractor Information:
6 14.WATER ZONES
Well Contractor Name 1 FROM TO DESCRiPT[O1V
ft. ft.
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING far multi-casedwells OR LINER a arable
(j FROM TO DIAMETER THICKNESS MATERIAL
Company Name R' ft' In. s
16.INNER OR TU9 NG Qeathermal elosed-loo
2.Well Construction Permit#: ny� -7 FRaM TO DIAMETER THICKNES5"' MATERIAL
List all applicable well construction pern ri is(i.e.UIC.Count},State. Parlance,etc.) ft. � ft. in.
3.Well Use(check-svell use): ft. ft. in.
Water Supply Well: I%SCREEN .
A Cnitural FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
� unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) ft. ft. in.
hri ation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METH OD&AMOUNT
Non-Water Supply Well: ft. fL
Monitoring MRecovery ft, ft.
Injection Weil:
Aquifer Recharge ElGrOundwater Remediation ft. ft.
Aquifer Storage and Recovery DSalinity Barrier19.SANDlGRAVEL PACK if a licable
FRO1H TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ' �Stormwater Drainage ft. ft.
Experimental Technology oSubsidence Control
ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG atti<ch additional sheets ifrecess
Geothermal(Heating/Cooling Rettnn) Other(explain under#21 Remarks) F Onf To DESCR1PTiON color,barrlaes%soilfrock type,grata sl etc,)
ft. ft.
4.Date Well(s)Completed: s Well ID# ft.
5a.Well Location: /y ft. R,
_`:` 1 PISA �BF'�� ft. ft.
Facility/0wnerNamc Facilityll)#(ifapplicable) ft. ft. -_
ft. ft. ;
Physical Address,City,and Zip ft. ft.
t
1 N �`1 21.RE ARKS
County h.s �{ e p
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Vo
(ifwell field,one lattiong is sufficient) 22.Certification:
N W
6.Is(are)the wells) . Permanent or Temporary Signature CertifieJ11 tractor Date
r
BY signing this form,I herebp certify that the arll(s)ivas(were)constructed in accordance
7.Is this s repair to an existing well: QYes or o with 15A NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Siandardv and that a
If this is a repair,fr11 out larown well construction information and explain the nature of the cop),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: 1
— SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:__ b (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,(ferent(example-3@ 200'arnd 2@100?
-9 construction to the following:
10.Static water level below to of casing:
lfwater level is above casing,use"+p
" (ft,} Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: q f—iy above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
EWATERUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
— Method of test: 1/ 24c.For Water SunDly Br infection Wells: In addition to sending the form to
I- the addresses) above, also submit: one copy of this form within 30 days of
type: Amount: 1D 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