GW1-2022-06915_Well Construction - GW1_20220725

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�)Amgn DANi- 1 ,j i wn 14i WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number
15 OUTER CASING for multi-cased wells OR LINER if a able
O e FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. to R5 in.
Company Name
16.INNER CASING OR T G eothermal closed-loop)
2.Well Construction Permit#: FROM TO 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. ft. in.
Water Supply Well: 17.!,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rlMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
htdustrial/Commercial Residential Water Supply(shared) I&GROUT
71 Irrigation FROM I TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. cgo I ft. s _ q-Gum
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.$AND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.10DRILLING LOG attach additional sheets Rnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
O ft. I ft.
4.Date Well(s)Completed: Well ID# 1 ft. I ft.
5a.Well Location: ia,
ft, 4 ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
CL k—AIVIZ Ke A b yI K- ft. ft.
Physical Address,City,and Zip
('I -AD K, 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) 22.Certification: A._,n o
e
RA A
6.Is(are)the well(s) Permanent or Temporary W gt ture of Certified Well Contractor ate
By si ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes oAnplain
o with 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well construction informatio the nature ofthe co of 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: p SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface:- -(ft-) 24a. 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') construction to the following:
' t
10.Static water level below top of casing: � (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: Le (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
c above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f�Z LS r construction to the following:
(i.e.auger,rotary,cable,direct push,etc) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
e
13a.Yield(gpm) Method of test: 1 �z 24c.For Water SunDiv&Infection Wells: In addition to sending the form to
\1 \ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ygn.1.�7 Amount:r3o 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