GW1-2022-06809_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-I) F r Internal Use Only:
1.Well Contractor Information:
14WATERZONES
Well Contractor Name F M ft. TO ft. DESCRIPTION
��(r' 4,303
(,3 0�
l U& —I J
PNC Well Contractor Certification NC umber t7� 1t nr► 15 OUTER CASING for multi-cased wells OR LINER if a licable
�t 1 z,®t 1 [- 'e 1 —C l i s lu min M ft. TO ` ft DIAMETER to THICKNESS MATERIAL
Company Name 16 INNER CASING OR TUBING eothermal closed-loo 0�
2.Well Construction Permit#: n 3M TO DIAMETER I 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
FR 3M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a ft.
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 201 DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks)
TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
ks) ft. a ft.
Uqu
t ft. ft.
4.Date Well(s)Completed:_— WellD#I 3 �� e�
5a. '1 .11Location: �QWrLT1rrs ` ft. t�f9 ft. �Di
ft. ft.
Facility Owner Name Facility ID#(if applicable) ft. ft.
00%1 l t_51R6 VIa NCR
Physical Address,City,and Zip
ft. ft.
C t{ a� 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)�.Permanent or ®ITemporary T23.Site
f Certified Well Contractor Date
, this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or No CAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio,¢anexplain the nature of thes record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
iagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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 wellsion details. You may also attach additional pages ifnecessary.
drilled: ( TAL INSTRUCTIONS
f
9.Total well depth below land surface: ��� 24 . For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') coi i struction t0 the following:
10.Static water level below top of casing: wot (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.) 24 .For Injection Wells: In addition to sending the form to the address in 24a
atit ve,also submit one copy of this form within 30 days of completion of well
yl
12.Well construction method: Al at �P3 fe I6 i.J 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(glint) A5 Method of test:Arciz 241..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.Disinfeedon type: Amount: (36 coi pletion of well construction to the county health department of the county
wl re constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016