GW1-2022-07742_Well Construction - GW1_20220819

Pr."'
WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
I.Well Contractor formation:
44.WATERZONES.
Well Contractor Name FROM TO DESCRIPTION
Yr9 2 f 8• � ib
G �J ft. ft.
NC Well Contractor Certification Number
r IS.OUTER CASING mnitieased weds OR LAVER Cif a 6cable
2W C— FROM TO I DiAMrrm THICKNESS MATIIUAL
Company Name & ft j in.
�oy�t/8�I�14�t6`I rQ�a/ _FFSROIIMFNERC roSWGORTI DYANF thermelelosed-too
2.Well Construction Permit#: Zf72 Z 7 nlAMrrER I •IHttcravESS MATERrAr,
List all applicable well construction permits(i.e.UIC,County,State,Variance,era) ft. ft. in.
3.Well Use(check well use): ft. It.
Water Supply Well: •17.SCREEN
FROM TO DIAMrrER SLOT SIZE Tt�CKNFSS MATERIAL Agricultural [3]Vfunicipal/Public ft r fa in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. % in.
:)Industrial/Commercial Residential Water Supply(shared)
-1&GROUT
Ir
rigation FROM TO MATERIAL EMPLACE11�T1TMETHOD AAMOURr
-Water Supply Well g• &
onitoring Recovery R &
ction Well:
uifer Rec ft barge �GroundwaterRemediationuifer Stora a and Recove I9:SAND/GRAVEL PACK ifa licable g ry Salinity Barrier FROMTo MATIItrAL EMFLACEMFdVT Mr1HOD
uifer Test oStormwater Drainage ft. e� it164
perimental Technology OSubsidence Control ft. ftothermal(Closed Loop) Tracer 20.DRII.LING LOG attachaddidona►sbeetsifnecesskmI
(Hearin Cooling Return) Other(explain under#21 Remarks 10tOM TO DESCRIMON color,hardness,saturoek qM grain sae,eta
� Z G Oft 2 f �
4.Date Wel(s)Completed:�� Well EN fi. 2 ft
Sa.Well Location: fL It. �T
LA-strc.. �ows,tc ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft +Im, s .! f
Sw 4q ft ftE , ,
Physical Address,City,and Zip ft. ft
c'`t/���/ 21.REMARitS ::sl. r .s s.9 a
County Parcel Identification No.(PIN) `ad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
3 .07 ff 89 N ?l ZO a V3 7 w
6.Is(are)the well(s) ermanent or E3Temporary Si Certified Well Con Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis 1s 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Q / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells h'st all depths 1fdijjerent(example-3Qa 200'and 2@100)For 2 For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: ( 7 (ft,) Division of Water Resources,Information Processing Unit If water level Is above casing,use"+" ng ,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _ G• (fro) 24b.For Infection Wells: In ddition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push.eta) 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
13a.Yield(gpm) Method of test: 24c.For Water Suoniv A Infection 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: completion of well construction to the county health department of the county
where constructed. V
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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