GW1-2022-08315_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
11
14.WATER2ONES ..
Well Contractor Name FROM TO DESCRIPTION
t�_
NC Well Contractor Certification Number 15.:OUTER CASING(for multi-cised,wells)OR LMR(if a'" licable
A ',11i `/�CJ FROM TO DIAMETER THICKNESS MATERIAL
c� I U V l 'V_I ft. I D rift. a in. li v
Company Name scb
t� t f6.INNER CASING OR TUBING "cothcrmal 66ed-loo .,
2.Well Construction Permit#:1�0a0 { 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 Well: 17..SCREEN._' -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural []Municipal/Public En e)ft. ft. Q in. O 1 ,l o ��v
:;)Geothermal(Heating/Cooling Supply) esidential Water Supply(single) G� ft ft. in. "l
Industrial/Commercial (Residential Water Supply(shazed)
18.GROUT. '..:..
1ti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ��ft. D'r J 2
__'Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19'.SAND/GRAVEL PACK(if a"licablc
_ Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ell Stonnwater Drainage ft. aG ft. a �nd PV 1(
Experimental Technology QlSubsidence Control
(�IGeothetmal(Closed Loop) E]ITracer 20.DRILLING LOG(at(ucli'addlti&iiAr k6ts if necessa )s ."
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) 011. 17 ft. --1 • ,
1
4.Date Well(s)Completed.✓�) Q Well ID# a ft. OL ft. 11a da
Sa.Well Location:/t , 9 ft. i ft.
�f A J CM UL_ ft. rl ft.
IFacility/Owner Na re Facility ID#(iiffapplilicable) ft. ft.
ej
�I��, D 1 i �o-"r \c oGOJI� Q ft. r�p ft.
Ph sical Address,hy,and Zip ft. ft.
����� 21.REMARKS"
County Parcel Identification No.(PIN) MAY Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IVI
(if well field,one lat/long is sufficient) 22.Certification:
,�
p� (/f�t/rj � „..fir �!�! g' I I�C7
6.Is(are)the well(s)Oermanent or (©(Temporary Signature of Vitified Well Co ctor VDate "
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• r1IYes or o 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 inform don rid 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 GW-1 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: t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@2 0'and 2@100� construction to the following:
10.Static water level below top of easing:_ Ct (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: MLP. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: V.'i l
'(��Ua above, also submit one copy of this form within 30 days of completion of well
�V�y�(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test:(�V 24c.For Water Supply&Injection Wells: In addition to sending the form to
II I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l Amount: /`II� completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016