GW1-2022-08510_Well Construction - GW1_20220518 (2)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
W l l I t 1 U y N JY 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�j `� �ft. ft. V-C.l' �l h
b� r ft. ft.
NC Well Contractor Certification Number �y 15.OUTER CASING(for multi-cased wells)OR LINER if applicable)
��► `(7� S �l e 11 ri 111 l FROM TO DIAMETER THICKNESS MATERIAL
-1~k ft. 3�C. ft. in. .Jl h VC,
Company Name +-� 16.INNER CASING OR TUBING'( eothermal closed-loop)
2.Well Construction Permit#: 14I- FROM TO I 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 ❑MunicipaVPublic 12
ft. L1 ft. ' in. t o
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ✓ ft. 1 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. CQ oft. 4rtt
❑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
❑Experimental Technology ❑Subsidence Control
[]Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessar
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. ft.
4.Date Well(s)Completed: -1 Ol Well ID# l
py ft. et. j.-t, l• g el t
5a.Well Location: ` ft. 2-3 et i1 C 1 to
1 �ft. 1
�rn�.c l`kA nS .J s
Facility/Owner Name Facility ID#(ifapplicable) 35-
ft. L \ ft. yr `
Physical Address,City,and Zip ' ft. ft.
21.REMARKS -
County Parcel Identification No.(PIN) mf.•" '�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
t
(ifwell field,one lat/long is sufficient) irAi
22.Certification: Ei'i f
6.Is(are)the well(s):Vermanent or ❑Temporary Signature of Cediried Well Contra or Date
,,�f/� 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 00 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 d 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: I (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@2�000'and 2 @I00')
10.Static water level below top of casing: �J (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (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
c Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 1 t 1 Amount: !"l
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018