GW1-2022-06185_Well Construction - GW1_20220701

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Ell.Contractor Information:—J.,I�,,O14:WATER ZONES
=v !�&�rj FROM TO DESCRIPTION
Well Contractor Name
Gd rt.
ug - G rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells)OR LINER if appllcable)
V✓off �1 ,�� FROM TO DIAMETER THICKNESS MATERIAL
ft. D ft. in. Q_(o
Company Name 16.INNER CASING OR TUBING(eothefind closed-too
2.Well Construction Permit# FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,Coungt State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE THICKNESS I MATERIAL
:)Agricultural [3Municipal/Public A ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R. g, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
H ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if n livable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorrnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop)) Tracer 20.DRILLING LOG(attach additional sheets if necessa
Geothermal(Heating/Cooling Return) __ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soft/rack VAw,grain sire,ete.
ft. ft.
4.Date Well(s)Completed: = J Well W# ft. ft.
So.Well Location:
; k pp//�� ft. ft. y
Facility/O/wnerName Facility ID#(ifapplicable) ft. ft.
6! ft. ft.
S 1/t
Physical Address,City,and Zi ft. ft. 77,1"1'
=:)O A 21.REMARKS `
4nty Y1 Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) 'm'Pdmanent or OTemporary Si ature or rtified Well Contractor Ilate
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: af. or ON. 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 l;W-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: UO 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example- a@200'and 2@100) construction to the following:
10.Static water level below top of casing: .94— (it.) Division of Water Resources,Information Processing Unit,
If renter 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
�� above, also submit one copy of this form within 30 days of completion of well
iz7 12.Well construction method: V19j_ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Nection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L4 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: f' Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016