GW1-2022-04230_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Wen Contrac nhon:
✓t F 14re 14:wATI&RZONES
FROM TO I DPSCREMON
Well C.Maor Name
ft 30 &
ft r
ft k
NC Well Contractor Number 15.:OUTER:CASING roc m welk'OR LINER d
FROM DIAMETER THICKNESS MATERIAL
6! in.
Nam .
Company Na
�O� 16::1NNERR.,: ,G OR:.TUDI tIG:
2.Well Construction Permit#: LFROM
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,Srate,Varume,etc.) ft- in.
J_
3.Well Use(check well use): ft m'
k-Urrigation
FN
ter Supply Well: OMM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural �M lit ft ft in
eotheimal(Heating/Cooling Supply) idential Water Supply(single) & ft in.,
ndustrial/Commercial QResidenbW Water Supply(shared)
,�S GRUF3T
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well & o ft' CO t? clit t
Monitoring DRecovery fL ft
Injection Well: fL fL
Aquifer Recharge ®Groundwater Remediation
19.SAND/GR&VE;;'PisCJ€ ' k
Aquifer Storage and Recovery ®Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainage ft `
Experimental Technology 13Subsidence Control & ft.
Geothermal(Closed Loop) Tracer 36�RIId IIHG:.i UC.amch atlttitienal sheela, '
FROM DFSCRIPrr herpes,
Geotiretmal(Heating/Cooling' Return) Mother( lain tinder#21 Remarks To tobr wWreck *e,etc
4.Date Well(s)Completed: Well ID# S^& ft
5aIl Lo n: fr ft.
0 ? fL ft 1 r -
Faetlity/OwnaName Fac 'ty D#(ifapplicable) ft ft 2
ft ft
PK'teal//pd_�� .� ,and lap
i
ft ftv_,t ( i'
V "J �/� 2}.REMARSS ,�t �•;� �, r.7 7�47 1,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one larllong is sufficient)
22.Certification:
N W
6.Is(are)the wells) ermanent or Temporary Signature of Certified Well Contractor p Daze
By signing this form, I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or � with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construa ion Standards and that a
If this is a repair fU out iron rv�l construmton information,and explain the naut a of the copy of this record has beer.provided to the well ownar.
repair render#21 rtmaris sectim or on the back of thisform. 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
L �
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For msdiiple wells list all depths if�erent(example-3 00'hand 2@1001 construction to the following:
10.Static water level below Lap of casing: 7 (ft) Division of Water Resources,Information Processing Unit,
if warer level is above caster&use"+"/ 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well constriction method:
above,also submit one copy of This form within 30 days of completion of well
�ar
(i.e.auger,rotary,cable,direct push, econstruction-to the following:
i
Division of Water Resources',Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service lCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test r _ 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: / 11 Amount: completion of well construction to the county health department of the country
where constructed. +
u
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016