GW1-2022-08043_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
QFjr�n 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
D C/L t cr-
� '- L Zsft. 3 3�ft.
NC Well Contractor Certification Number 15.OUTER CASING for'multl catieU'iveus OR I IiVEK tf a nwbte '
/� I _ �E '• ,� a��L FROM TO DIAMETER TZ`CKNESS MATE AL
ft. in.t. U
Company Name 16.INNER CASING OR TUBING Lathe rmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply WeU: FROM 1tEE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft.
- in.
Geothermal(Heating/Cooling Supply) ' Residential Water Supply(single)
-_ Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
'Irrigation FROM I TO MATERIAL EMPLACEMEryr METHOD&AMOUNT
Non-Water Supply Well:
Monitoring i_ Recovery
Injection Well:
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL:PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEM1IENT METHOD
Aquifer Test f3Stomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
L
Geothermal(Closed Loop) Tracer 20.DRILLING LOG.(attach additional sheets if n )
FROM TO DFSCRUMON color,hardness,willoek n etc
EGeothermal(Heating/CoolingReturn)
i=' Other(explain under#21 Remarks) Ft. ft.
3/122
4.Date Well(s)Completed: 8—12 -2�ell Em ft. ft. i
Sa.Well Location: ft' ft.
ft. ft. �--_.: _
ft. ft. . t..
Facility/�Owner Name / Facility ID#(if applicable)
Qr/ 7AUG l / '
l�►r' '' C t:f ft. ft. 9 99 - -
Physical Address,City,and Zip
���� ft. ft.
21.REMARKS
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:
6.Is(are)the well(s)�tmmnent or Temporary Si tore of Certified e o clot Date
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 10 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the hell mvner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 constriction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 V (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (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: 6 D fj (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/f above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,12.Well cot method: �� y construction to the following:
ry,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: OL441 � 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: Amount: h(A., 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