GW1-2022-04051_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES,"
Well Contractor Name FROM TO DESCRTMOO/N�
ki� ft. "i � ft r'1
I Aft. �` ft.
NC Well Contractor Certification Number I5,:.OATER CASING-for:inalti-cased wells OR!LINER(ifa licable
C-Ird'al &L \4�� � FROM I TO DIAMETER THICKNESS MATERIAL
Q ft ft. in. ,
Company Name
(.,{{ 16.INNER CASING O11TU131N eothe'iq closed=too"
2.WellConstructionPermit#: t�� � S.�O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e. UIC,County,State, Variance,etc.) ft.
3.Well Use(check well use): tt. ft, in.
Water Supply Well: 17.SCREEN' .:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public tt. ft, in.
Geothermal(Heating/Cooling Supply) 66Rcsidcntial Water Supply(single) ft. fL In.
lndustrial/Commercial DResidential Water Supply(shared) 18:'GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. ft, a'gja
e
N
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDiGRAVEL:PACK(if a licablc
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20..DRILLING:LO4(at6ch'additional sheets.if riecess
Geothermal(Heating/Cooling Return) 0 Other(explain trader#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock a grain size,etc.)
ft. ft. C Ja
4,Date Well(s)Completed: 3 42 Well ID# I A ft- — ft. �e,
elu
Sa.Well Location:
r ft, Soo
ft.
ft. ft. �_17 y'> 1 I:,-T:T r
} �
Facility/CiAerName Facility ID#(if applicable) ft. ft.
3[o a� T' APR `
�r ��S° ft. ft.
Ph ii I Address,City,and Zip `(y ft. ft.
�0 REMARI{S 1.""'�F :i , �7,, �,.•,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 3mr�—��
6.Is(are)the well(s)[dPermanent or OTemporary Signatur o Certified Well ContiNetor Date
By signing this form,I hereby certify that the itwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JNo with 1511 NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out knout well construction information and eiplain the nature of file copy of this record has heea provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S.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: Soo (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 200'and 2@100) 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 Injection 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: ou r 1 r 6 construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: fl 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: `J 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
131b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016