GW1-2022-07882_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW 1) or Internal Use Only:
L Well Contractor Information: v�
I ,WATER ZONES
Well Contractor Name F OM TO DESCRIPTION
N(��('� Q(IAu
YYW1
NC Well Contractor Certification Number
1 .OUTER CASING(for could-cased welts)OR LINER(if a licable)
1�' F OM TO DIAMETER THICKNESS MATERIAL
Company Name ft. t ft. D5 in, G
I6 INNER CASING OR TUBING( eothermal clos 400 )
2.Well Construction Permit#: F OM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cmauty,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17 SCREEN
Agricultural FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
g []Municipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Ir7 anon FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. eft.
Monitoring rMl Recovery
Injection Well:
A uifer Recharge a ft. ft.
q g Groundwater Remediation
Aquifer Storage and Recovery Salinit Barrier 19.SANAIGRAVEL PACK(if a ticable)
y FR M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stonmwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Rerun) r
Other(explain under 421 Remarks) FR M TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft t ft.
4.Date Well(s)Completed: Well ID# L ft I ft.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft
Physi al Address,City,and Zip ft. ft.
.? 0 21. EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 Certification:
N W d-
-0 - aa.
6.Is(are)the well(S) Permanent or OTemporary Sig rat re of Certified Well Contractor Date
By iguing this.forin,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No wi u 1-A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
IJ'this is a repair,fill out known well construction information Lnd xplain the nature ofthe copy o('this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. i
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:
^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o !!``� D r (ft-) 24a.For multiple wells list all depths tor All Wells: Submit this form within 30 days of completion of well
ifdf#&rent(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing:
L7`LJ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.Nor 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: Unll S constnIction 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) :) Method of test: 1 ) 24c. FIOr 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: Amount: C 7V completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016