GW1-2022-06822_Well Construction - GW1_20220725

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:LL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
,dell Contractor Information:
c
�R`'P-` \, �Gn 14.WATER ZONES DESCRIPTION
v r Ct``C5J I �J FROM TO
well Contractor Name ft. ft.
& Y e- ft. ft.
NC Well Contractor
�Clertification Number FROM TO�!IV-1 1p( 15.OUTER CASING for multi-cased wells OR LINER if applicable (`
1 l I ! �+l t [1 ( � 6 ft. l ft. DIAMETERin. �1 Okt �TMCKNESS TE v
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
M FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V ft• ft. in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM 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 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
hri ation
Non-Water Supply Well:
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SANDlGRAVEL PACK if a livable
Aquifer Storage and Recovery n Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necess
FROM TO DESCRIPTION(color,hardness,sail/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. !� ft. 05
ed
4.Date Well(s)Completed:�d^^��+� Well ID#AAe 1r
ft. ft.
5a.Well Location-.
--��Faci�lity//Owner Name Facility ID#(if applicable)
_BQ90 KSMOR0 I
10
ft. ft.
Ph ica Address,City,and Zip ft. ft.
ni1 n^n 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Jwi
ertification:
I
N
R.
6.Is(are)the well(s) ermanent or Temporary tore of Certified Well Contractor Date
Op *Plain
gning this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information 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
construction only 1 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: `TC J (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:
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 Iniection Wells: hi addition to sending the form to the address in 24a
9 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 13 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) c'3b Method of test: iFF l )� 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: 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