GW1-2022-08367_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
met. 5
NC Well Contractor Certification Number r� 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
\\` ,�1�(\ 1 ,I/i1`i FROM TO DIAMETER THICKNESS MATERIAL
1 V ` l �/1 in. n JQ,
Company Name Sch
` -'4 16.INNER CASING OR TUBING(geothermal closed-oo
V )
2.Well Construction Permit#: k C1 �b 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 ft ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in. `� V
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (D L?C) ft. t
t(11 0i1� 'Z
❑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 EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology El Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft. et. r
4.Date Well(s)Completed: I > Well ID# ft. ft. ri �'Ca
11
2-3
5a.Well Location: ,t ft. ft'�S�� Ep_ 6 ft. ✓1 ft.
FaciGlity//Owner^Name `^ 1Fa1cidlity�I+D#(ifappl�ic`able) l
1 In o �7 1` �Qb �UmCA w I\V- ft. fL
Physical Addregqss,,�City,and Zip /� ft. ft.
Pir t7LIL>� (�3 51 T 3 Lf,�3 21.REMARKS MAY ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °'=
(if well field,one lat/long is sufficient)
22.Certification: lx�,�;rru,r t(,�a: r+'✓,�t-�+•�''�����
t-I..Lome SZSe N ` 'IS i�k I3 r94 W L l 2
6.Is(are)the well(s): grmanent or ❑Temporary Signature of Cc&9fed Well Cont for 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 t 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 an d explant the nature of the of this record has been provided to the well owner.
repair tinder#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: 5'� (ft.)
For multiple wells list all depths if different(example-39200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
as 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
p (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: \ 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
r�
13a.Yield(gpm) Method of test: �)(Yl
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
1i
13b.Disinfection type: Amount: V L4 Cl-1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018