GW1-2022-06303_Well Construction - GW1_20220707

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: Print Form
6 !.;,_Well Contractor Information: c
V� 1.�� t `t��� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number ft.
a 1 c 15.OUTER CASING for multi-cased wells OR LINER(if a licable
DIAVIE 1"j ^ FROM TOTER THICKNESS MATERIAL
Company Name a ft• t ft• 25 in.
LAt>M
V
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(:.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
fr.
Industrial/Commercial Residential Water Supply(shared) ft. in.
is.GROUT
hfi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ftoto. t ft.
Monitoring DRecovery ft. ft.
Injection Well:
A uifer Recharge ft• ft.
q g Groundwater Remediarion
Aquifer Storage and Recovery �{Salini Barrier 19.SAND/GRAVEL PACK if a licable
`-+ ty FROM TO MATERIAL EMPLACEMENT METHOD
NAquifer Test oStormwater 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(wlor,hardness,soil'ock e, rain size,etc.)
j� ft. t ft.
4.Date Well(s)Completed: Well ID# V ft. t fr.
5a.Well Location: ft. ft.
4ft. ft.
Fac /Owner Nzei Facility ID#(if applicable) ft. ft.
gWIJ n ft. ft.
Physical A dress,City,and Zip ft. ft.
u 1mk1 ty 21.REIVIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
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6.Is(are)the well(s) Permanent or 13Temporary Si tune of Certified Well Contractor Date
By si ning 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 with SA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information plain the nature of the 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
t SUBMITTAL 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)
construction to the following:
t
10.Static water level below top of casing: d (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method �1% above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rot construction to the following:
g rotary,cable,direct push,etc.)
r
Division of Water Resources,Underground Injection Control Program,
fN FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: Y t 1 iZ 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:l 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