GW1-2022-06298_Well Construction - GW1_20220701

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WELL CONSTRUCTION RECORD (GW-1) or Internal Use Only:
1.Well
Contractor(Innfotr�mation:`
115 6T) i .WATER ZONES
Well Contractor Name OM TO DESCRIPTION
ft. ft.
ft. ft.
NC Well Contractor Certification Number
p 1 OUTER CASING for multi-cased wells pR LINER if a Gcable
e n OM TO DIAMETER THICKNESS MATERIAL
Grp I` /) ft• ft. -W in. PVC.
Company Name V t
K�i Ili 16 INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:y= 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 SCREEN
M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural M
unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) ft. ft. in.
hldustrial/Commercial Water Supply(shared) 1$GROUT
hTi atiori FRM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. ,
Monitoring ®Recovery
Injection Well:
ft.
Aquifer Recharge nGroundwater Remediation ft.
Aquifer Storage and Recovery {�Salim Barrier 19.SANDIGRAVEL PACK if a licable
fJ Salinity FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FB M I To I DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
ft. !t�I ft.
4.Date Well(s)Completed:t�-aq- Well ID# Q[� [ ft. 6
6 i ft.
( 5a.Well Location:
Facility/Owner Na—me et Facility ID#(iifapp liicable) ft. f.
buIz aiC10% ft. ft,
Physical Address,City,and Zip ft. ft,
CIA 21.REMARKS
County 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 W IDWAiJ,
r
c �cs�
6.Is(are)the well(s) Permanent or OTemporary i e of Certified Well Contractor Date
By igning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or VNo i i SA 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 of the co ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.S'te diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay 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 const uction details. You may also attach additional pages if necessary.
drilled: f
SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') const ction to the following:
t
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: U (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
s1►I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IN const ction 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) Method of test:_Y{f UC 24c.I ror Water Supply&Injection Wells: 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: Pa Amount: C-50 comp etion of well construction to the county health department of the county
wherc constructed.
Form GW-1 North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016