GW1-2022-06167_Well Construction - GW1_20220701

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�14.WATER ZONES'
Well Name FROM TO DESCRIPTION
el
ft. t ft.
1-44/ge,C ✓ ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING'(for.multi-cased'rvells)OR LINER(if a Ilcable)
FROM TO DIAMETER I THICKNESS MATERIAL
�Q�'� (/1�! S �i I�(�• 7 ft. -,3ft. in. :5 A._Q&
Company Name
;16:INNER CASING.ORTUBING �etithermalclosed-loo
2.Well Construction Permit#: FROM 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.
17.SCREEN
Water Supply Well: ;
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural IDMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEME METHOD&AMOUNT
Non-Water Supply Well: ft. ^? ft.
:]monitoring ec a fery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
%.19.SAND/GRAVEL PACK(if applicable),
Aquifer Storage and Recovery DSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) W
Geothermal(Heating/Cooling Return) '_ Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,gmin size,eta)
ft. ft.
4.Date Well(s)Completed: IC�� Well ID# ft. ft.
Sa.Well Location:
/rJ,��` Q`� ft. ft.
Facility/Owntr Name /I1 / Facility ID##(if applicable) ft. ft. _ L
1/�•t j�� (,���'�pi (iV� �®'1 , /(�f ft. ft. lf1•fvYlci.:.'x`Yi'7 4'fi+:zi' ::dui U!lit
Physical Address,City,and Zip
,n ��•�� 21.REMARKS.
County /�j—` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CAMS"I en:9
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the 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 G 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: t�,b (ft-) yqa•For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'aannd 2@100) construction to the following:
10.Static water level below top of casing: V-d (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: �C�?8J� 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 form to
4 .� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / it Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016