GW1-2022-04867_Well Construction - GW1_20220520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
14.WATER ZONES
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Well Contra or Name FROM TCD, DFSCR�TION
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3 5 L- 90 ft_ s 60 �- i v n1
NC Well Contractor Certification Number
1S OtTi'ER CASING for multi-rased wells OR L1NER ria livable
1 Ohi TO DIAM_M THICKNESS MA
4-on 51 e g's W Q.l l �r ��1 vt_ 1►rl�,. is
Company Name 4 t
16 R CASING OR TUBING ralhern al closed4ti6
2.Well Construction Permit#: / FROM TO DIANWrER I IMCK iESS MATcurnL
List all applicable well construction permits(Le.UIC,Courrty,State once.eta.) It, It. in.
3.Well Use(check well use): ft B in.
Water Supply Well: 17.SCREENFROM TO DIAMETER. SLOTSIZE THICLQim MATERIAL
Agricultural DMunicipal/Public O ft_ M in.
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) R irr
RIndustrial/Commercial Residential Water Supply(shared) M GROUT
lrrigation FROM TO MATEMkI1L. EMPLICEMNT METHOD&AMOUNT
P
on-Water Supply Well: v ft '3 ft.Monitoring Recovery IL �0 H.jection Well:
tt R
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(da 'auble
Aquifer Storage and Recovery Salinity Barrier FROM 170 1 MATERML f EMPLACEMENT YdKMOD
OAquifer Test [3Stormwater Drainage ft. ft
HExperimental Technology Subsidence Control ft. IL
Geothermal(Closed Loop) Tracer 20.DRII LING LOG attach additional sheets ifuecessa
Geothermal(Heating/Cooling Retum) rJOthcr(explain under 921 Remarks) FROM TO DESCRIPTION(color,bardna�,sorihock type,gmin 9&%eta
4.Date Weil(s)-Completed: I WellIDl/ 0,: M L66 It
Sa.Well Location:. �l) . M. .g g. M l'(-o L"n j eGt i m Err r f`OcJry
J ts�1� L�.t,IsQh .. �.� .. I�os 'SAL,
Facility/Owner Name Facility IINl(if applicable) R
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Physical Address ,and Zip R R
21.REMARKS
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County Parcel Identification No_(PIN)
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4�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,:one lat/long.is sufficient) 22.Certification: MAY.2, 202
N 97 5.
d a Contract r Ui iitj'i jr'i�•. ty.
6.Is(are)the weil(s)OPerman Signature oCertifie
ent or Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or [KNO with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ythis is a repair,fill out known well construction.information and explain the nature of the copy of this record has been provided to 66e 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 tdtneh additional pages if necessary.
drilled: , SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �d 7 (R•) 24a..Foe All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3®200'and 2@100) -
construction to the following:
10.Static water level below top of casing: VL) Division of Water Resources,Information Processing Unit,
Ifwater level is above rasing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: ro.
n n(• ) 24b.For Injection Weils: In addition to sending the form to the addriss in 24a.
12 Well construction method: 77)2 I�OT1�2 above,also submit one copy of this form within 30 days of.completion of well
construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mari.Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) 1 O Method of test: IC5 24c.For Water Supply&Insertion 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: brl .— Amount: 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