GW1-2022-08365_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor hdor�m'ation:
L Y � V V 11 11�/
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor}Name Z� 1 1�_ft. as ft. W � T C Ta r ,i h
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Wc1111�\ i 1�L FROM TO DIAMETER THICK
�NtESrS MAATERIAL
Company Name , _r 16.INNER CASING OR TUBING(geothermal closed-loop)
y�2.Well Construction Permit#: C 1 I � 060 +`� 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 P5 ft- a ft- in. Ql Sc l�t` r p v`
❑Geothermal(Heating/Cooling Supply) tsidential
sidential Water Supply(single) ft. ft. T
❑Industrial/Commercial Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
P11 ft. / ft. i-
4.Date Well(s)Completed: �1 1 - Well ID# ft. `�/ et. ::!r a h
5a.Well Location: ft. f ft. 4 C 1
21 ft. dun -t,,h 1^}-e l
Facility/O ner Name Facility ID#(if applicable) Z,ft' IT ft.
HL O Ve 7w-\,J M!0 Dc4 \Zbk. MR, ft. ft.
Physical Address,City,and Zili
,/ r�-.•�� hh ✓� ft. ft.
'-
' U,v�n � �� ��V V p Q l�' 21.REMARKS
l
County Parcel Identification No.(PIN) r.� n.rn�'�.Can^'�,' ":f'i Ill I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) t 22.Certification:
3� I WO KQ N `Y�l0Q t -I O p OS�Lp W c f a
6.Is(are)the well(s)- [�rmanent or ❑Temporary Signature ofC feed Well Contr ctor Date
By signing this form,I hereby certify that the welt(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 06
0 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 and 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 @100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing:�-Y (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use i"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 1 TWA 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: VA TA Amount: ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018