GW1-2022-06305_Well Construction - GW1_20220707

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: Print Form
1.Well Contractor Information:
V" `r Name
a v - i�y�6 - MWATERWell Contractor Na(me� DESCRIPTION
JWft.ft.NC Well Contractor Certification Numberfor multi-cased wells OR LINER if a licabie
r— FROM TO DIAMETER THICKNESSI MATERIAL
t {Company Name dV) ft. 1 ft. eZ5 in. "
/ M 16.INNER CASING OR TUBING eat hermat closed-loo
2.Well Construction Permit#: ILrI 010�[000(Q[q 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
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) nResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Non-Water
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
r Supply Well: Q ft. I
Monitoring ®Recovery ft. ft.
Injection Well:
A uifer Recharge ft. ft.
q g Groundwater Remediation
Aquifer Storage and Recove 19.SAND/GRAVEL PACK if a licable
ry [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) I
FROM To DESCRIPTION(color,hardness,---I/rock type, rain size,etc.)
� ft. 1 ft.
4.Date Well �ys)Completed: t (� `t Well ID# A a,0 ft. o ft.
5a.Well Location: /� n 1�f� ¢ /�/{ ft. ft.
c ���W 1 V.J�U'LJC/o ft. ft.
Facility/Owner me Facility ID#(if applicable) ft. ft.
` n ft. ft.
Physical AdUMJ,City,and Zip t ft. ft.
1 �-"K 21.REALARKS
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
6.Is(are)the well or Temporary 65A
ore of Certified Well Contractor ate
ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or o 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 thef 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
constructign,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: V
I SUBMITTAL INSTRUCTIONS
For multiple wells list all depths
9.Total well depth below land surface: �� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
if different(examplee--3@200'and 2@100') construction to the following:
10.Static water level below top of casing: L�' (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:,L__(in,) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: I above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) Construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Ot- Method of test: 24c.For Water Supply&Iniection 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:56 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