GW1-2022-06307_Well Construction - GW1_20220713

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WELL CONSTRUCTION RECORD(GW-1) or Internal Use Only:
1.Well Contractor Information:
a ri l 5 U 1- b o n 14 WATER ZONES
Well Contractor Name F11 OM I TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number
�1 C 15 OUTER CASING for multi cased wells OR LINER if a licable
1 1 bon � , `PO �j- 1-'D �,� M TO DIAMETER THICKNESS MATERIAL
111 l a/V t�-t .J- ft. �(�([ft. in. G
Company Name V t
16 INNER CASING OR TUBING eother al closed-loan)
2.Well Construction Permit#: FR M TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
AgriCUltural FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)R_R ft. ft.
:)Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O Q
Monitoring Recovery ft. ft.
nd
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK fif a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
NAquifer Test [3 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) Other(explain under#21 Remarks) FR M TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
pp ff +�^� ft. � ft.
4.Date Well(s)Completed: `L I- � Well ID# r ft. t ft.
5a.Well Location: ft.
Faaccilrityl/Owner Name Facility ID#(if applicable) ft. ft.
C s-K 1721, N c:, ft. ft.
Physical AddWCity,and Zip — ft. ft.
01411 21.RENIARKS
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 t t
10
6.Is(are)the well(*ermanent or Temporary Siure of Certified Well Contractor Date
By i 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 ffNo wit 5A 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 f this 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_`VP 00 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') cons Ction to the following:
10.Static water level below top of casing: JYU (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 Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1(Z r9, 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) Method of test:A 24c.For Water Su only&Injection Wells: In addition to sending the form to
f,�� ���� the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�qa1 1S7 Amount: C1C� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016