GW1-2022-05834_Well Construction - GW1_20220606

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C=�AM c5 ban-se-1 _03y`50o 14.WATERZONES
Well Contractor Name FR M TO DESCRIPTION
`,�f
ft. ft.
NC—WC-NC-WC- 1���iJ6A
NC Well Contractor Certification Number 15. UTER CASING(for multi-cased wells)OR LINER if a licable)
`�O ; FR M TO DIAMETER THICKNESS MATERIAL
Company (Name 0 i U ft. �?I ft. t:k5 in.
0 1)r V C,
16.INNER CASING OR TUBING( eothermal closed-loo ) �l
2.Well Construction Permit#:_O d� 1'C�' FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft ft, in.
Water Supply Well: 17. CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. ` • L w
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage
Experimental Technology Subsidence Control
FRo ft. ft.
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. t ft.
4.Date Well(s)Completed: b-`i-X? Well ID# JDr)Q• '16 I U
ft. 18 t ft. Deco For-1c
�
Sa. ^Weell Locati@tI:
ft. ft. s
\,h�1 on 1 Am
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
�{SaGI'}}pA 4A 1B5Y111Ef MC., 21209
Ph sica ft. ft.
y�s,City,and Zip
C 4 br'^ 1131 Aq S a-3 21. EMARKS
County JParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Clertitieation•
N 1with
t
061�
6.Is(are)the well(s) Permanent or OTemporary re of Certified Well Contractor Date C,�-
ing this form, I hereby certf&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repairfull out known well construction information nd explain the natue ofthethis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis./brm.
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: I SUBMITTAL INSTRUCTIONS
4 9.Total well depth below land surface: DW (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@a 100') construction to the following:
10.Static water level below top of casing: f_iL! (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: lie (in.) 24b.Eor Iniection Wells: In addition to sending the font to the address in 24a
J�
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:A 12 4 A rQ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.for Water Supply& Iniection Wells: In addition to sending the foam to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �6 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