GW1-2022-08388_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �\`
�Q 1M \J \�1 \y1(J� �Y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
l lt� T S.Jft. ��ft. Ct 1rS a rk-' o
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
t , `-ei 1 ^�6 ; �� FROM TO DIAMETER THICKNESS
MATERIAL
Company Name
r 16.INNER CASING OR TUBING(geothermal closed-loop)
`
2.Well Construction Permit#: ,�C b�I J 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 50ft. -Dft. A in. t ®1 a S0040 VC-1
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial K.idential Water Supply(shared) 18:GROUT
[ Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a® et. Ct1k_bnl+ a,5-
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑StormwaterDrainage ft. u ft. I t,2 sr
❑Experimental Technology ❑Subsidence Control ft. ft
❑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,soil/rock type,grain sin,etc.)
Q ft. It.
�� r
4.Date Well(s)Completed: Well ID# ft. r11 ft. em 4 616a
Oj ft. /(� ft.
Sa.Well Location: ` l "/1 4
/a
fL ft.
Facility/Owner Name Facility ID#(ifapplicable) t. �vc It.dKImpi
�Z-oka QQP l NS NC- �k�a+� �O et. nfc. S�n a,
Phxsical Address,City,and Znp ft. ft. Ty.,_kn: a ,11, 9�:.--1
21.REMARKS IM AY `
County yJ� V 1 lA Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ifwell field,one lat/lon is sufficient _` �I'r'1,� �ljJt � `i'7 ii�tl I
C g ) 22.Certification:
t .J 3l5) N I O I �l I o� W a'
6.Is(are)the well(s): Permanent or ❑Temporary Signature of C ified Well Co f actor Date
/ _ By signing this form,[hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information a nd 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: i ^ 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-3@200'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If 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: (in,) 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
�1 �,,• Program, 1636 MSC,Raleigh,NC 27699-1636
t�^
12.Well construction method: Y�1 R=CN ,PA 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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
� �U`(Y�'Q1�
13b.Disinfection type: Amount: 1l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018