GW1-2022-07045_Well Construction - GW1_20220801

nt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . PH
1.'V tell Contractor Information:
U � a I i_l 0 1 Isnn 14.WATER ZONES
Well Contractor Name FR TO DESCRIPTION
,��{
ft. ft.
('.WIA Lk3o
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
'1600 1 h 1 i FROM TO DIAMETER THICKNESS MATERIAL
`� ft. ft. ^ in. r'� t/-G
Company Name d
16.IJNNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM, To I DIAMETER 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. CREEN
FROM TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18. ROUT
hri ation FRO TO MATE L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q i ft.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19. /GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FRO TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets if necessary)
FRO TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 49 ft.
4.Date Well(s)Completed:7-62 g-ova well EM ft. L4 ft. Shod
Sa.Well Location:
ft, ft.
ft. ft.
ER,N -,i n a ro.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
ei
C Z'\ ft. ft.
Physical Addres,City,and Zip
ft. ft.
In
County 21. MARKS
County `v ` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 .Certification:
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N W 7•��
6.Is(are)the well(s) Permanent or Temporary t t of Certified Well Contractor Date
By 'g ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes orNo wit 1 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio n explain the nature afth cop this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
3.S to 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: I C SUBPJITTAL INSTRUCTIONS
9.Total well depth below land surface: W (ft-) 24a. �or 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') construction to the following:
10.Static water level below top of casing: ao (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.gor Injection Wells: In addition to sending the form to the address in 24a
°n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: )R U �
(i.e.auger,rotary,cable,direct push,etc construction to the following:
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: A I JZ 24c. or Water Su I 1 &Injection Wells: In addition to sending the form to
'�^ the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: {. Amount: C:38 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