GW1-2022-06297_Well Construction - GW1_20220701

Print Form
WELL CONSTRUCTION RECORD(GW-1) r
Internal Use Only:
1.Well Contractor Information:
AM G) . � 1 Lt 5c, 14. ATER ZONES
Well Contractor Name FR M TO DESCRIPTION
NC Well Contractor Certification Number 15. )UTER CASING for multi cased welts OR LINER if a livable
t a FROM TO DIAMETER THICKNESS MATERIAL
IL wi?lt ft. I MtD ft. s�1� in. kpMr I �!G
Company Name f �✓ 16. ER CASING OR TUBING(geeothermal closed-loo L
2.Well Construction Permit#: r�L( (J[Jt JO CW 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: 17. CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) LaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18. ROUT
hri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: —IL F1 ft. t ft.
Monitoring Recovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19. ANDlGRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology FR Subsidence Control ft. ft.
Geothermal(Closed Loop) JDTracer 20. RILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
��p 4,�, ft. �ft.
4.Date Well(s)Completed:e��a.g as Well ID#IlfJo` O=--, ft. Avas rC
Sa.Well Location:
ft. ft. V
ft.
ft. ft.
<'M mt'
`Facility/Owner
Nafmrep�. r Facility ID#(if applicable) ft. ft.
MtiMh mL Physical A ddress,,City,and.Zip
f. f.
icPIZAy, &y.Qc% b4E9
21.1 1EMARKS
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
e
6.Is(are)the well(s) Permanent or Temporary r ure of Certified Well Contractor ate
77rrr7"������ By i ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No wi 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 n explain the nature ofthe co c fthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.S to diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You ay use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: l JIJIQr (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: (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:.0 (in.) 24b. For Injection Wells: hi addition to sending the form to the address in 24a
'n tp p ��` abov , also submit one copy of this form within 30 days of completion of well
12.Well construction method: IN 1 1Z/ J
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
D vision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) j Method of test: JZ. 24c. or Water Supply&Injection Wells: In addition to sending the form to
'Q� �, the dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:I TM T61fJ5 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental QuE lity-Division of Water Resources Revised 2-22-2016