GW1-2022-08343_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:aw \/V�1`,1 � -Ty\/
14.WATER ZONES
Well Cont1racttoorlNaame FROM TO DESCRIPTION
IX l�1113 aft. a ft. CA
ft. ft.
NC Well Contractor Certification Number I 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
1 � FROM TO DIAMETER THICKNE"SS(, MATERIAL
r\ 16 V�J ` yV t ` -1-� ft. �ft. in. S l'�4(
Company Name
�� Ob �� 16.INNER CASING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit#: FROM TO G DIAMETER THICKNESS I 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 02ft. oZ tit. in• 101
D, Sun
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 02 c)
[]Monitoring ❑Recovery
Injection Well:
et. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage a D ft. a ft. n
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
©ft. ft. 0,0 S r,)'
4.Date Well(s)Completed: - I a a Well ID# il. ft. r I S K►tul r:
5a. ee11Locatioon: ft' of aft' �n uJ C!ICAVI
V aXb d L) l KbY'n S ft. 2 4-ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
qqq q --T i rr bvh� R A
Physica�ddress,City,and Zip 1 ft. ft-
�`\\JJ 21.REMARKS
County Parcel Identification No.(PIN) MAY 17 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient)
22.Certification: �;•; -
lj:i
3 a DI-0 N I LS �� �J�2 W1��
c 4 r o%C� Zv 2
6.Is(are)the well(s): C/ermanent or ❑Temporary Signature of Certi dwell Contract Date
' • By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well ❑Yes or 1j o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information a4d�explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )( (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-36f00'and 2 @100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+1" n
11.Borehole diameter: `E' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ' I IW I P)pyrx VIA 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing-over 100,000 GPD: Copy to DWR,CCPCUA
n 13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
� 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018