GW1-2022-08316_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:�_ 1 V l � �V 'i 1 V fbi U 7/
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 LAI ft. rCA
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
,� '+11 � 1^, I '\ 11`I 1,� __ FROM TO DIAMETER THICKNESS MATERIAL
qI
` �j r 16� 1 1 l fG 1 1 ft. in.
Company Name Ca
(C)DO 16.INNER CASING OR TUBING eothernwl closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I 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 I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural DMunicipal/Public 1 ft. L 1 ft. in. I 9VC
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT. ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
['Monitoring [3Recovery
Injection Well:
ft. ft.
�_ Aquifer Recharge [3 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
M TO Aquifer Storage and Recovery ©(Salinity Barrier FROMATERIAL EMPLACEMENT METHOD
Aquifer Test rJ]Stormwater Drainage ()ft. I ft. V:2 sanA
Experimental Technology QlSubsidence Control tt. ft. L
Geothermal(Closed Loop) ❑7(Tracer . 20.DRILLING LOG(attach additional sheets if necessit )_
FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,eta)
HGeothermal(Heating/Cooling Return) (Other(explain under 421 Remarks)
4.Date Well(s)Completed:_10 5 r 2' Well ID# ft. ft. -e;f.-i
5a.Well
l(Location: ti Z` ft. t^ l
ft 2-1 L fG tA`
Facility/Owner NAne Facility ID#(if applicable) p ft. ft.
1 NMV%an, _ RJ
DuAleA4
Physical Address,City,and Zip 04 ft. ft. MAY I
`
Rcu)no so^ / W ®n ' I UQ Y7� 21.REMARKS
County Parcel Identification No.(PIN) 15t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 22.Certification'
3 - y4w3g N `J -. 3o 1 $ W e
6.Is(are)the well(s) (pPermanent or OTemporary Signature of Certifi ell Contractor —� Date
J7JJJ���"''' By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well ❑(Yes or 9nd
o with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationxplain the nature of the copy of this record has been provided to the well 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
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: I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2 a 100� construction to the following:
0'
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,used+j' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: b (in.) 24b.For Injection 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: rn R.o IM 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) L Method of test: (-G' 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: 1 l I *� Amount: 1`7, 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