GW1-2022-05680_Well Construction - GW1_20220616

WELL CONSTRUCTION RECORD GW-1
or Internal Use Only:
`1.Well Contractor Information:
<A ni WATER ZONES
Well Contractor Name OM TO
/� � ft DESCRIPTION
( 4301 . ft.
NC Well Contractor Certification Number ft. ft.
OUTER CASING for multi eased wells OR LINER if a licable
1 G F M TO DIAMETER THICKNESS MATERIAL
Company Name ® ft. 40 ft. ar in. ` `r
2.Well Construction Permit# 1 INNER CASING OR TUBING( eothermal closed-loo ) C
List all applicable well construction permits(i.e.UIC,Cowity,State,Variance,etc. F M ft TO DIAMETER THICKNESS in. MATERIAL
ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
Agricultural ®IMunicipaUPublio F M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Coolie Supply) ft• ft. in.
g pp y) Residential Water Supply(single)
Industlial/Commercial ft•
Residential Water Supply(shared)
Ini ation 18. ROUT
Non-Water Supply Well: FR M TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
Monitoring ft'
Injection Well: ft. ft. TI
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19. AND/GRAVEL PACK if a licable)
L_JFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stornwater Drainage ft. ft.
Experimental Technology Subsidence Control
ft. ft.
Geotherinal(Closed Loop) Tracer 20. RILLING LOG(attach addi0onal sheets if necessar
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FR TO DESCRiP ION(color,hardness,soil/rock e, rain size,etc.)
ft. ( ft.
4.Date Well(s)Completed: 2.,?L Well ID#
C 5`a.hWelell Location: 3 1 ft. ft. n
0�5 ft. ft.
Factlrty/Owner Name �p ` Facility IDt1(if applicable) /� ft• ft.
�P11�0If1 + f-t14[.) Yt!�P �Q/�td ft. ft.
Physical Address,City,au Zip ft. ft.
21.1 EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.C rtificatiml:
N W t a p
6.Is(are)the well(S) Permanent or Temporary ig at a of Certified Well Contractor `Date ,
By s i jig this Jbrm,I hereby certify that the well(s)was(were)constrrtcted iri accordance
7.Is this a repair to an existing well Yes or No ill 1 NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
ll'this is a repair,Jill out known well construction i4lbrination n explain the nature of the copy o his record has been provided to the well owner.
repair under##21 remark section or on the back o/'this.1brur.
23.Six,diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Your lay 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 constr iction details. You may also attach additional pages if necessary.
drilled:_ I
SUB TTAL INSTRUCTIONS
9.Total well depth below land surface: db(r7 (ft•) 24a. r Ail Wells: Submit this form within 30 days of completion of well
For imdtiple wells list all depths iJ'diJJerent(example-3@-00'acid 2@100')
constr ition to the following:
10.Static water level below top of casing: t
If water•level is above casing,use — (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: to
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b, r Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: �1 l� r above, itlso 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:
FOR WATER SUPPLY WELLS ONLY: Di i don of Water Resources,Underground Injection Control Program,
J� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:_t"t 1 i-k 24c. F Water Stionly& Injection Wells: In addition to sending the form to
the ad ess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: compl t on of well construction to the county health department of the county
where bristructed.
Form GW-1 North Carolina Department of Environmental 0-1i:h- �f W­.Dew,,,. e