GW1-2022-06301_Well Construction - GW1_20220707

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:WELL Form
_I.Well Contractor Information:
`-��� `"� ►�, � % l5an 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number ft. ft.
r 15.OUTER CASING for multi-eased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
v Company Name G�f-�t It- 1 ft. Q5 in. !0 r
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit# 0 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.
�f�l
Water Supply Well: 17,SCREEN
AgriCUltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
:)Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. �t ft.
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge ft• ft.
q g []Groundwater
Aquifer Storage and Recovery 13 Salinity Barrier 19.SAND/GRAVEL PACK if a licable
E
Aquifer Test � FROM TO Stormwater Drainage ft. ft. MATERIAL MPLACEMENT METHOD
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) bother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
n �'_''� O ft. ► ft.
4.Date Well(s)Completed: Well ID# t ft.
5a.Well Location: 10 i q ft. ft. Q
ft. ft.
Facility/Owner N ne Facility ID#(if� applicable)
1 ft• ft.�Q ( u to �— 1 �. L li f)1 itF� it. ft.
66 Ph{yssiical Address,City,and Zip
rr to-V��� QA/�yc�(� 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
6.Is(are)the well(s) Permanent or Temporary nature of Certified WellContractor ate —
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: []Yes or o wi h 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 nd"explain the nature ofthe c py ofthis 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-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: 8 LD For multiple wells list all depths tf different(example 3@200'and 2@I00� Olt-) 24a. For All Wells: Submit this form within 30 days of completion of well
-
construction to the following:
10.Static water level below top of casing: 7� (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 Iniection Wells: In addition to sending the form to the address in 24a
)_� 1 () �(� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:�
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
c
13a.Yield(gpm) Method of test: 24c.For 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016