GW1-2022-07886_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD (GW 1) or Internal Use Only:
I.Well Contractor Information:
1 .WATER ZONES
Well Contra Mew-� n(c+tor Name
( F OM TO DESCRIPTION
- Lyo�i' ft. ft.
NCC Well Contractor Certification Number ft. ft.
15 OUTER CASING(for multi-cased wells)OR LINER(if a licable)
e of)
(' I ��{' �j I E�1 n� �nC F OM TO DIAMETER THICKNESS MATERIAL
6�t�Sb!V l t`
Company Name rt� ft. 1 ft. A5 in. 1)F— FV.Ci
l.J
16 INNER CASING OR TUBING( eothermat closed-loop)
2.Well Construction Permit#: FR M TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction pernnts(i.e. UIC Coratty,State,Variance,etc.) ft ft in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
h7i ation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:Monitoring Recovery fL ft. `7
Injection Well:
A uifer RecIt a ft. ft.
q g Groundwater Remediation
Aquifer Storage and Recovery Salinit Barrier 19. AND/GRAVEL PACK(if applicable)
y FR M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Storinwater Drainage ft. fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessar )
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FR M To DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
ft. t ft. L1
4.Date Well(s)Completed: '►`LSD' Well ID# t ft. Doi ft. R
5a.Well Location: otft. t ft.
ft.
Facility/Owner Name \ +Facility IDq#(if applicable) ft. ft.
Physical Iddress,City,and Zip ft. ft.
l �)(J P 21. EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.C rtification:
N W C
AkA
l(o-
6.Is(are)the well(s) Permanent or Temporary Si rat re of Certified Well Contractor Date
B sigzing this.1brin,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ayes or No with 1 A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
#'this is a repair,fill out known well construction irtforination and plain the nature of the copy o Yhis record has been provided to the well owner.
repair raider#21 remarks section or on the back gfthis form.
23.Si a diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You r)ray 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.
I
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:multiple welds list all depths I�0 (ft•) 24a.
F or All Wells: Submit this form within 30 days of completion of wellForn i/'different(eranap e-3g 200'and 2�100')
conshlction to the following:
10.Static water level below top of casing' ^ I
(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: ( 1) (in.) 24b.kor Iniection Wells: In addition 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
t?f 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
/� J� c `�
13a.Yield(gpm) o�U Method of test:_A,, Z 24c.I r Water Supply& Iniection 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: TN,A'I? Amount: c_ZiN 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