GW1-2022-06674_Well Construction - GW1_20220708

Prin#Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES l '
FROM TO DESCRIPTION
Well Contractor Name L ,
fL
i
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased6wells OR LINER If a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER Ft-
List all applicable n•ell construction permits(i.e.U1C.County,State. Variance,etc.) ft. ft. in.
in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaUComtnercial OResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
`, Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL Ea1P1,:10EMENT METHOD
Aquifer Test DStormwaler Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM ft To DESCRIPTION(color,hardness,soil/rocke, rain size,etc.
Ca rt• Arc;,.`', to
4.Date Well(s)Completed:6� � ' L Well ID# `"�� (��R3 o ft. /. �
/ /•
5a.Well Location: / /
11 1G/l `L. C ,3 C ft. ft• p r Cl --? '
ft.
Facility/Owner Name Facility IDN(ifapplicable) ft.
7qS 7 GYk, l��'//�ti� ' '�� � Q
ft. ft.
Physical Address,City,and Zip
21.REMARKS PF
County Parcel Identification No.(PIN) re" 0-6c," C"e Y t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: q
(if well field,one lot/long is sufficient) 22.Certification: '/'&� O`v �C'c `4 t n✓u c:!-J- Cj/� f'Y'EC.�!i.:Tt�
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor -- ter- Date
By signing this/arm.I hereby ceriift that the well(s)ma.c(here)constrncted in accordance
7.Is this a repair to an existing well: []Yes or WNW with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.02n0 Nell Construction Standurds and that a
//this is a repair.ill out known well construction information and explain the nature of the copy g/'diis tecorcl has been provided to,the nvell owner.
repair under tl21 remarks section or on the hack 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 I 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: . S� (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdr.c ifdi/jr'reru(example-3Tcf.20n'and 2Gy 1nn') consu-action to the following:
10.Static water level below top of casing: ! y (ft.) Division of Water Resources,Information Processing Unit,
lfeater level is above casing,uce"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection 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: / �. construction 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: 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
completion of well construction to the county health department of the county
136.Disinfection type: Amount:
where constructed.
i
I
Revised 2-22-2016
Forth GW-I North Carolina Depanment of Environmental Quality-Division of-a-Resources
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