GW1-2022-07898_Well Construction - GW1_20220831

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
14:WATER ZONES
Well Contractor Name FR M TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number
r r 15.OUTER CASING for multi-cased wells OR LINER if a licable
Q 4 ( _�10 11 f-1 t 1C„(� FROM TO DIAMETER THICKNESS MATERIAL
C� \A I ,I Vl ft. in. c-
Company Name �J
j,'�1 R^I/� /t�/,, 16.INNER CASING OR TUBING( eothermal closed-loo
2.Well Construction Permit#:ILY 9(39(VUcxy FR)D1 TO I DIAMETER I THICKNESS I MATERIAL
List all applicable weld construction permits(i.e.CIC County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): Ft. ft. in.
Water Supply Well: 1 SCREEN
FR7. M TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
PGeothermal(Heating/Cooling Supply) Residential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18. ROUT
hTi.ation FR 111 TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK(if aDolicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO )1ATF.RIAL I EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage
NExperimental Technology OSubsidencc Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG(attach additional sheets if necessa
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FR nt To DESCRIPTION(coior,hardness,soil/rock type,grain size,etc.)
f ft. Z ft. m) 5 p
4.Date Well(s)Completed: -p2x Well ID#�_��0Q6[p[ELj ft lJ r` e Ci
5a.Well Location: ft ft. .
14-1p-n a e ►(b ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Ph5�J�
Address,City,and Zip t� ft. ft.
0 - 21. MARKS
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
X,,,�1 N W _� �a
6.Is(are)the well(s) Permanent or OTemporary (],B�i,
gn t ne of Certified Well Contractor Date
�y Yt� si (ring this form,I herebv cerlVf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes of 1Vo 1$d NC.AC 02C.0100 or 15A NC.1C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knoum well construction informatiar an eaylain the nature of the copy o f this record has been provided to the u ell 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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i
rr^r ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 W Cn (ft.) 24a. tor All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example(-3@)20'and 2(u 100') construction to the following:
'TIl C
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.for Injection Wells: In addition to sending the form to the address in 24a
ll above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 tz ) V 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
13a.Yield(gpm) Le Method of test: 1 24c.For 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: Y pi` Amount: (3U 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