GW1-2022-06182_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i. 1 ll Contractor Information:
�..�� '334:•WATER ZONES.
r e
FROM TO I DESCRIPTION
Well Contractor Name /pt, /' ft.
ft. V ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased`wells)OR LINER(if a Hc2ble)
FROM TO DIAMETER THICKNESS�w MATERIAL
in- 15
Company Name 16:;INNER CASING OR TUBING( euthermal closed-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.
Water Supply Well: SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural [3Mum ipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v' ft. 70 ft.
:]monitoring I ecovery ft. ft.
Injection Well: ft. ft.
i Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology ! Subsidence Control ft. ft. � -
Geothermal(Closed Loop) Tracer 10.DRILLING'LOG attach additional sheets if necessa )'.
Geothermal(Heating/Cooling Return) FlOther(explain under 921 Remarks FROM ft. To ft. DESCRIPTION color,hardness,soil/mck type,grain size,ete.)
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Facility/Owner Name
/�,���� / Facility ID#`(if applicable) ft. ft. JUL 0 12022
�(��/�Y� 1� LO� � �•�IJLy p"'��/`f ft. ft. _ ;� p--.-z..,A..;,� _ .
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/Wnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
`N / °��`!S);G(L/� W Vy�I c�Wwv�C✓
6.Is(are)the wells) vent or Temporary .429
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: es or f7No 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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
/�)
9.Total well depth below land surface: (t (/ (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@220000''adn 2@100� construction to the following:
10.Static water level below top of casing: C9 i,a/ (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: r (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: 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) 0 Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount: completion of well construction,to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016