GW1-2022-06179_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
14-WATER ZONES
i
FROM TO DESCRIPTION
Well Contractor Name I� r 6 it. 1U / fL'7 �► r� �J ft. ft.
NC Well Contractor Certification Number J5.OLTTER CASING for could-cased-weLLvJ OR LINER(if-up licable
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. IL in-
Company Name .16.INNER CASING ORT[JBWG eothermat closed-lc
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): ft. ft. in
rAgricultural
Supply Well: 17.SCREEN
PY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OMunieipal/Public 0 ft. ft. in.
al(Heating/Cooling Supply) esidential Water Supply(single)UCommercial Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT b'eZ OD&AMOUNT
Non-Water Supply Well: ft. O ft. ASP I&
Monitoring ecovery ft. ft.
Injection Well:
tt. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalm[ty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage
I_ Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) '�
i Geothermal(Heating/Cooling '_Return) Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness,wilhoek 4Tw,wnin stir,dam)
4.Date Well(s)Completed:60 1. Well ID# ft. ft. _
Sa.Well Location:
r
m� R ej �� - ft.
Fa/ciliVty/(Owner Name r_ Facility ID#(if applicable)/ ft. ft.
IV-G ��`L"�� ft. ft.
•: �,,
Physical Ad_ -City,and Zip [t. ft.
O P 21.REMARKS
Co ty Parcel Identification No.(PIN) e
5b.Latitude and longitude in degrees/minutesAmonds or decimal degrees:
(if well field,one lat/long is sufficient) r� 22.Certtfication:
S6?9�K!3 wA 7%�1, W
6.Is(am)the well(s)QHeEmanent or OTemporary Signature of Certified Well Contractor Date
4 signing this form,I hereby cer!!fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 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 GY-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: Sh (ft-) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following-
10.Static water level below top of casing: `mac (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. (in.) 24b.For Infection 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: /�Od Oy`rY 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 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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: Amount: 0 ayecompletion 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