GW1-2022-07803_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) Pr1nt Form
For Internal Use Only: !
1.Well Contractor Information:
1C WATERZONES
Well Contractor Name FROM TO DESCRIPTION
It.
ft flA
NC Well Contractor Certification Number P
w 15.OUTER CASING for 'ti-eased Wells)OR LINER tf a licable
DIAMETER THICKNESS MATERIAL
Company Name etc. ft O in.
� s MANNER CASING OR TUBING eotherbtal closed loo
2.Well Construction Permit#: !�/ZL•O yam`/�'�L(�t/Q`r��r✓Q/ FROM I I DIAMETER THICIQVFSs MATERIAL
List all applicable well construction permits(ie.UIC,County,State,parlance,etc.) ft. ft, in.
3.Well Use(check well use): ft. % in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMEI Fdt SI OT SIZE THICKNESS MATERL1i
-- � �Municipal/Public ft ! � �.
ff
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft. I in.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL. EMPLACMH N T METHOD&AMOUNT
Non-Water Supply Well: gr ft, fL
2t4onitoring _ Recovery ft ft
Injection Well:
'A uifer Recharge �GroundwaterRemediation fL fL
_Aquifer Storage and Recovery Salinity Barrier ]F9ROSM ND/GRAVEL PACK H a liwble :
MATERIAL EMPLACENMa METHOD
_Aquifer Test [3Stormwater Drainage (� ft. ft.
Experimental Technology E3Subsidence Control ft ft
Geothermal(Closed Loop) E3Tmm 20.DRILLING LOG attach additional sheets if necess
Geothermal eating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardn sodfroek rain live,eta
I t� &- y fi- �ii/
4.Date Well(s)Completed: ZL Well ID# s"1 W 2 fL &
5&Well Location: ( f1. 2 ft
C $ 0 o tl�� ft, ft.
Facil//ity/Owner��bl• a Facility ID#(ifapplicable) It. ft s ."
D.
Physical Address,City,and Zip 1L ft. AJJC, 1 9
n
22
6 vrr%(eo 3L REMARKS-
County Parcel Identification No.(PIN) if C 1 Przne`&q�irJ Unil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
•075�4S N W-f0r(16•
6.Is(are)the well(s) Permament or Temporary Si of Certified Contractor D 2 .Z�
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: Yes or �No with I5A NCAC 02C.0100 or ISA NCAC 02C.020o Well Construction Standards and that o
!f this is a repair,fill out known well construction it formation 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:
9.Total well depth below land surface:
2 SUBMITTAL INSTRUCTION
For multiple wells list all depths ifdtfferent(example-3 a(�00'and l®/00') (ft) 24a. For All Wells: Submit jthis form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: tZ
lfwater level is above casing use +^ (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: • ? rn,)� l
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: < G E 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield m
(gP ) Method of test: 24c.For Water Sunnty&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: Amount: completion of well construction to the county health department of the county
where constructed.
r ;
Form GW-1
Nonh Carolina Department of Environmental Quality_Division of Water Resources Revised 2-22-2016