GW1-2022-07900_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) V,or Internal Use only: Print Form
1.Well Contractor Information: `` ( �
�P-me 0 tJLJ ti 1 (1 n 14.WATER ZONES
Well Contractor Name F OM TO DESCRIPTION
ft. ft.
W_WC 4363 ft. ft.
NC Well Contractor Certification Number
15 OUTER CASING for multi-cased wells OR LINER if,, licable
O F7 1 f n 1Rr+ F OM TO DIAMETER THICKNESS MATERIAL
Lt t ity� ft. ft. in. ©�at CL-�
Company Name �l l 1G
D 16 INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:1l�( D© FRORI TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.CIC,Cotmtr.State,I�ar•iance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FR aI TO UTAMEI'ER SLOT'SILE 'THICKNESS MATERIAL Aricultural Munici al/Public
® P ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
1S.GROUT
011T"itzation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. Q �v• _ I.{
Monitoring Recove 'L
Injection WeRell: ® rY ft, ft.
fL ft.
Aquifer charge 0 Groundwater Remediation
A uifer Storage cord Recover 19, AND/GRAVEL PACK if a licable)
tI a y [DSalinity Barrier FR M TO �IATF.RIAt, EMPLACEMENT METHOD
Aquifer Test [DStomlwater Drainage
Experimental Technology oSubsidence Control
Geothermal(Closed Loop) [3Traccr 20. RILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FR M TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
r1 ft. I ft. I
4.Date Well(s)Completed: ` / Well ID (� Q 3 ft. tft.
5a.Well
-Location: te f. ft.
ft.f. f.
Dgm(oylaE6 —aw Ni i
Facility/Owner?flame Facilit`yy` ##ID (ifapplicable) ft. ft.
1 Y L ft. ft.
Physical 4dress,City,and Zip ft. ft.
Yl&1z1 KP_P_ WabAq l 45 LLW 21. MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or OTemporaty Si.at are,of Certified Well Contractor Date
14 By igning this farm,1 her•eb.v certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: '3 Yes orqN. wi 1 A NCACO2C.0100or 15A NC.ACO2C.0200 Well Construction Standards andthata
lf'this is a repair,ill out known well construction mJornrationsprain the nature of the opy this record has been provided to the Hell owner.
repair corder#21 remarks section or on the back oJ'this,orm.
23.Ste diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You i
lay use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBP ITTAL INSTRUCTIONS
9.Total well depth below land surface: bbb (ft-) 24a. or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a)�200'and 20','100') construction to the following:
10.Static water level below top of casing: SU 1
(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: t (in.) 24b.for Iniection Wells: In addition to sending the form to the address in 24a
Ih �7 above]also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y`t 1 6 14174 constr�ction 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) 13 Method of test A
1 24c.For Water Su only&Iniection Wells: In addition to sending the forni to
y� the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:3O compl tion of well construction to the county health department of the county
where]constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016