GW1-2022-07591_Well Construction - GW1_20220817

Print Form•;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We 1 Contractor Information:: /
�Ia 1/V 14.WATER ZONES
Well Contra or Name FROM TO DESCRIPTION
qq/!�lq CO ft. 1/1(0
ft.
i
NC Well Contractor Certification Number v' Cd ft ` 7
15.OUTER CASING(for multi-cased wells)OR LiNER if a livable
�„ - FROM ft- ft.
ft. DIAMEIlITER to THICKNESS TERIAL
Company Name ) !y`L / 7 ". ,
Sa`/�✓LLi✓ZZ 16.INNER CASING OR TUBING( eothermal 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.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
Agricultural Municipal/Public ft. ft. to
_:,')Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_i Irri ation FROM TO ATERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: O t't. �f/f ft. t- ., 1`
Monitoring ®Recovery
Injection Well:
Aquifer Recharge Groundwater Rcmcdiation
FROM
SAND/GRAVEL PACK Ma livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION •olor,hardness,soil rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) )Other(explain under#21 Remarks) R. ft.
4.Date Well(s)Completed -ZZ-2Z WeII ID# ? ft. 7 ft f
5a.Well Location:
% /t_
Facility/Owner Facility ID#(if ap ft applicable) ft. •
d�J C' /�S eZ,,s,41, 6,`r, 4. ft. ft. p
Physical Address,City,and Zip
ft. ft.
r/ 43(titz 21.REMARKS
County /Patrcl Identification No.(PIN) i MV 4013
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
hit/long is sufficient) 22. e Ic tion:
�f/ ?6 70.0f'/ W
6.Is(are)the well Permanent or 13Temporary S n e`af1eCrtificd Well Contractor Date
By signing this form,/herebv certify that the well(v)was(were)constructed in accordance
7.is this a repair to an existing well: nYes or _ o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction infornhation and explain the nature of the copy of this record has been provided to the,.ell 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 13 (ft.) Division of Water Resources,Information Processing Unit,
If water level is shove casing,use6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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: D Y, 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) 16 Method of test: 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: �rl Amount: ��7• completion of well construction 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