GW1-2022-08467_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lr�A �N 1 1t� 14.WATER ZONES
Well Contractor Name y� FROM TO DESCRIPTION
CAS b�� tT j CA Yl h
ft. ft. ,
NC\Well 6Contractor Certification Number 15.OUTER CASING(for multi-chsed wells)OR LINER(if a livable)
1 FROM TO1 DIAMETER THICKNESS MATERIAL
}'1 ft' `V0 ft. 'l in. \(C_
Company Name P�
1 0-U 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
1-4
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 3aft. ft. in• a SLh PV
❑Geothermal(Heating/Cooling Supply) Ce tdential Water Supply(single) ft. I ft. in.
❑Industrial/Commercial 6Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ® ft. ,N�
❑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 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 0 ft. 3 S ft.
❑Experimental Technology El 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, rain size,etc.)
[�
ft. ft.
4.Date Well(s)Completed:q 1a 1 Well ID# ft. ft. i­rUAIA n lu
5a.Well Location: sl` ft. V, `i 1 et
ft. ft. Gl CK G (a
`Facility/Owneerr Name (� Q�,, Facility ID#(if applicable) O ft. 5r ft. rx� c h iv eYl
Zl` 1 d'l a l -e-\J Szo yn 0 ft. ft. U
Physical Address,City,and Zip ft. ft. r ,r -W-
21.REMARKS "'a``ss S r'c` a ?rt_ -
County Parcel Identification No.(PIN) MO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if field,one lat/lon is sufficient ,(ii ry
C g ) 22.Certification:
N w •� 0 Lf
6.Is(are)the well(s): Lhrmanent or ❑Temporary Signature ofCe fled Well Con ctor Date
/�' By signing!Iris form,I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M10 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 we➢l 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: S5 (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'acid 2 @100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Stalk water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use"+
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: 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
is
13b.Disinfection type: 01A Amount:
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018