GW1-2022-06219_Well Construction - GW1_20220620

Print Form:_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /�
!.(�� e��y,l U�SL`O rQ 2 �!. �,�/y 14.WATER ZONES
FROM DESCRIPTION
Well Contractor Name Z��f• �Q ft 6 r L�. Sr,r el
6 76 14 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased.wells OR LINER:if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CSC o-�C� �I'.�l�o'y rL ft. in.
Company Name 16.INNER CASING OR TUBING eothermaI closed-Ito .
/2.Well Construction Permit#: FROM TO ' DIAMETER THICKNESS MATERIAL
ft.Qn �' j in.
rt.
List all applicable ivell const action pernrils•(i.e.UIC,Cower,State P lance,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: RI&GROUT
DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. in,
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. in.
Residential Water Supply(shared)Industrial/Commercial � PP Y( O NT METHOD&AMOUNT
Irri ation _ ft.Non-Water Supply Well: ry 7, qMonitoring nRecovery� , „ 3 „x + fInjection Well: „ ft.
Aquifer Recharge Groundwater IQNiat�n0 2022AVEL PACK if a licable
Aquifer Storage and Recovery DSalinity Barrier c tti FROM TO MATERIAL. EMPLACEMENT METHOD
_,r�t:� i S�fC'?<�,,.,✓..+ Ira ft. f[.
Aquifer Test OStormwl i Df95(1 �51;
,., G r�dG
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionaIsheets if necessary)
D • rain
rl
Geothermal(Heating/Cooling Return) Other(explain underl�#21 Remarks) FROM TO ESCRIPTION(color,hardness,soiUrockc e, sae,etc.
4.Date Wells)Completed: Xl—ZL Well ID#��D d� <5fc. ft' reaU.� O1i rdl' '
5a.Well Location: r')
V"Cetl�iP�CO Kid,
Facility ifa licable ft.
y ID#( ft.
Facility/Owner Name PP )
ft. ft.
Physical Address,City,and Zip
n _ 21.REMARKS / 1
0��r tlCsd /� I�eilab
(�' ` �s��v,t,e� D t^Ovlin
County Parcel Identification No.(PIN) e i" o C�1'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r,� s , 2_ it
(ifwell fiend,one lat/long is sufficient) /1 7 /Yp 222..Certification: / q/
3-5
1111�
Signature of Certified Well Contrac r Date
6.Is(are)the well(s) Permanent or Temporary
Br signing Ihic liunr,/hw•ef,r c•ertiJi,that the wells)was(were)constructed in accordance
n existing well: [DYes or No with 15.d NCAC 02C.0700 or 1 SA NCAC 02C.0200 Well Consa•uctiotl Standards and that a
7.Is this a repair to a
Ifthis is a repair,fill out knout well construction in(ornation and explain the nature gfthe copy o(lhi,r record has been provided!o 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 GW-I is needed. Indicate TOTAL NUMBER of wclls
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: © (ff) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdi(Jerenl(example-3Lg200'and 2 ta/o0') 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 Infection Wells: In addition to sending the fora)to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: a construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
[13a.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016