GW1-2022-07238_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.gWell Information:�ontractor
M WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
L04949-'
ft. ft.
NC Well Contractor Certification Number
�` u 15 OUTER CASING for multi-cased well's)OR LINER(ir a lle)cabl '
W i � I`Cf� FROM TO DIAMETER THICKNESS MATERIAL
ut/ , ft. GW ft. 506LA;in. JJM. ,
Company Name +&INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO 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: FROMR. TO DIAMETER SLOT SIZE THICKNESS MATERIAL •T
:)Agricultural 3Municipal/Public Q ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. Ft. in.
IndustriaUCommercial Residential Water Supply(shared) 1S:GROUT
Im ation FROM TO CMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,
Monitoring ERecovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation
­19:SAND/GRAVEL PACK if appiivable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer ;1-20.DRILLING'LOG(attach additional sheets if necessa )
Geothermal(Heating/Cooling Return) � Other(explain under.#21 Remarks) FROM TO DESCRIPTION color,haness,soil/rock t n size,etc
' nn
rd
4.Date Well(s)Completed: d� Well ID# r
5a.Well Location: AUG 0 ft. ft. ,
2022
/I I _i� 40�
(���' ft. ft.
Faclility/Ownerr Name
'^ �Q 'Facility
C�ID^#�(if
�applicable) Infmnaiien Prt>c&aairt UNq
�J O 0011-Z5 FW1 G� / U O ft. ft.
Physical Address,City,and Zip
`21.REMARKS .
,c
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
ql W
=�`�-�p/��Cr�Oi'F� In n
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or E3No with 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 and explain the nature of the copy 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / �td (ft.) yqa,For 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:
r i
10.Static water level below top of casing: �J' (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'l 1617 Mail Service lCenter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 7`a+� 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: 16%Mail Service l enter,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: 24c.For Water Supply&Iniection 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: O�SP�' completion of well construction l,to!the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016