GW1-2022-07741_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW 1) Prilit Forn
For Internal Use Only: !,
1.Well Contractor Information:
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14-WATER ZONES e
Well Contractor Name FROM roj:�� DESCRIMON
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ft ft. f
NC Well Contractor Certification Number
,/, IS.OIUTER'C oING formutli-casedweps OR LINER tfa" liable
or V��jvC I DIAMETFdt THICIdVESs MATERIAL.
Company Name ft & in.
Lt4 ^� � A 16.INNER CASING OR TUBING eothermal dosed loo
2.Well Construction Permit#: � a7l 18,y -+Gwo/ FROM I To DIAMETER TIICXNESS MATERIAL,
List all applicable well coWniction permits(i.e.WC,County,State,Yartance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17:SCREEN
Agricultural Municipal/Public FROM TO DIAMT'M SLOT SIZE TMCIINESs MATEWAL
ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial oResidential Water Supply(shared)
IS.GROUT
IlrlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL fL
onitoring DRecovery ft ft.
Injection Well:
Aquifer Recharge E3Groundwater Remediation R'
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
�' MIE
TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test oStormwater Drainage 9 ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) DTracer
20.DRILLiNG:LOG-attach additional sheet if necessary)
I'Geothermal(Heating/Cooling,Return) _) Other(explain under#21 Remarks FROM To DESCREMON cola,hant„ soit/ruck e,grain etc
�" r v ft2 ft r
4.Date Well(s)Completed: 8 Z twell ID# /'7 J ft. Z & 4 C
Sa.Well Location: __// ft.
v ft
6R-fSG �o ACAC fL ft. V
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Facility/Owner Namdf Facility IDk(ifapplicable) R. ft
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` o1 S. 5wl*6 4*0 ft. fL -
Physical Address,City,and Zip
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2L REMARKS -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iat/long is sufficient) 22.Certification:
36 - d ?SS43N ?9 • �oB37 w
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6.Is(are)the wells)[3Permanent or [ITemporary Srgna of Certified Well Contractor Dam
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: E)Yes or [3No with 15A NCAC 02C.0100 or ISA 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 921 remarks section or on the back of thisforin.
23.Site diagram or additional well details:
S.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:
2/ SUBMITTAL DVSTRUCTIOIV
9.Total well depth below laud surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@I001 �
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+'• '� 1617 Mail Service Center,Raleigh,NC 276994617
il.Borehole diameter: �O• ) I
()n. 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /IvG G` above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following.
i
FOR WATER SUPPLY WELLS ONLY: Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test 24c.For Water SunDIv&Ini tion Wells: In addition to sending the form to
13b
the address(es) above, also submit one copy of this form within 30 days of
Disinfection type; Amount 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
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