GW1-2022-06180_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
14.WATER ZONES
�6 FROM TO DESCRIPTION
to
Well Contractor Name n,1 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a Ilcable)
FROM TO DIAMETER THICKNESS MATERIAL
b
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. [t. in.
3.Well Use(check well use): [t. ft. I in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
' Agricultural E)Municipal/Public G ft. ft. in•
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. et.
Monitoring ecovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. [t.
Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG attach additional sheets if necessary)
w�
Geothermal(Heating/Cooling Return) i_,Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilttvck type,gmin size,etc
4.Date Well(s)Completed: •���7/2� Well ID#
R.
5a.Well Location:
/jllemi a& ft. ft. JUL 0 1 �.
Facility/Owner N a Facility ID9(if applicable)
Ft. ft. ^^-4, cry tJrl:
Physical Address,City,and Zip
A_94 l 21.REMARKS
C unty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N - %. ') clw/vvw-
6.Is(are)the well(s) - rmanent or Temporary Signature of Ce red Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or [3No 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 lite 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�I 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:
p y LI (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 1 rr 100') construction to the following:
10.Static water level below top of casing:_ � (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 Iniection Wells: In addition to sending the form to the address in 24a
n rn� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �L'�'�Y 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) r% Method of test: 24c.For Water Supply&Iniection Welts: 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: 14 1— Amount C 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