GW1-2022-08305_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: {I
Lc"'A w(.1-'tl I��y�V v 14.WATER ZONES
Well Contractor
pNa a FROM TO DESCRIPTION 11 ,^,
���" ( Yl W�N* ! ✓ SCl
ft. ft.
NiC Well Contractor Certification Number ` 15.OUTER CASING for multi-cased wells OR LINER(if a 'licable
1)\\ l�`�•,r iC (�l�`` 1�1`1 FROM TO DIAMETER THICKNESS MATERIAL
111 l ��UU 1 N Is V V 1 �/ l f[. ft.
Company Name
S�� ryr1�I 16.INNER CASING OR TU131NG 'eotherntul closed-too
2.Well Construction Permit#: I c I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) '( ft. 1 ft. in.
3.Well Use(check well use): ft. 1 ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public it. ft. in.
oZ 1 3� ®oa Scin+�© pv�
Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial �IResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o
(-Monitoring Recovery
Injection Well: poor
ft. ft.
r Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACT((if applicable
Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (®_IStormwater Drainage
Experimental Technology MI Subsidence Control
Geothermal(Closed Loop) FnITracer 20.DRILLING'LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) ft. ft.
-h QS 1
4.Date Well(s)Completed: ) P Well ID# ft t� ft.
Sa.Well
Location:�( /y ft. ft.
Aof c 1 Z 2 l\l./�\0 ft. 2.5 ft. n
Faflclihli y//O Yner Name il�� ,/y� ii1 Facility IIDD1#�(if applicable)
1( ft. ft
I oli 1 yo* r�LI c'5 W,
Physical Address,City,and Zip -
`�`n 21.REMARKSMAY 17 -
County `1 ' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Ind" + "'� Y114IJL Jerl,vl I.I I
,mot 1 22.Certification:
36T IIO• I�0 N ��� A W
6.Is(are)the wells) (Permanent or )Temporary Signature ertified Well ontractor 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: QIYes or 14No with 15.4 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 well owner.
repair under 421 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
construction,only 1 GWA 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: (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 2@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: 1� (in.) 24b.For Iniection 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: M construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: v 24c.For 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: YI Y 1 Amount: L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016