GW1-2022-07047_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
k7 14.WATERZONES
FRO TO DESCRIPTION
Well Contractor Name
ft. Ft.
4-6 613 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
c
r \l ��� w �t ``�,(f I n A FRO TO DIAMETER THICHIVESS MAT`E,RIAL
w '� l c`r t ly-It 6 ft. 31. ft. :6.
C' in. P lC c-
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROMTO 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: FRO GREEN TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft. in.
hidustrial/Commercial ®Residential Water Supply(shared) 1s. ROUT
hTi ation FRO TO TE L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ®Recovery
Injection Well:
P-lft. ft.
Aquifer Recharge rl Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROMTO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.ORILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) et. a s ft.
4.Date Well(s)Completed: - Well ID# 0
ft. bt,iwt- &V-Qn
ft, ft.
//5a.Well Location:
-1- f�C E
Facility/Owner Name ,,``,�_`F`accilitQy ID#(if applicable) ft. ft.
n �i- Q �l 4�V s �t 1 1 @.� lVC-� ft. ft.
Physical Address,City,and Zip I ft. ft.
21. MARKS
County I 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:
N W �
6.Is(are)the well(s) Permanent or Temporary Si ure of Certified Well Contractor ate
By i Wing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No wi 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information,6n explain the nature of the py 4f 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
constructipn,only 1 GW-1 is needed. htdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 `w (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: ® ,lJl) (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: (D (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method <<Z 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: �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �d Method of test: W 1 I\ 24c.''For Water Supply&Iniection Wells: In addition to sending the form to
tt Z� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �L� Amount:Zw 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