GW1-2022-08675_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
C, C WC C 14.WATER ZONES
FROM TODESCRIPTION
Well Contractor Name
DIf t't' 10 S IL S
C
57 7- P . f V�
f �NC Well Contractor Certification Number 15.OUTER CASING for niulu cased wells UR LINER If a usable
A` e 2 L/V 1 Z AI CT/1: s FROM TO DIAMETER TIIICKNESS MATERIAL
Company Name O ft. 1 VZ) ft. m. -e 1 401 PVC
I6.INNER CASING OR T[JBING(eoth&mal closed-loop)_
2.Well Construction Permit#• 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): t't. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Nblic 0 ft. ft. in.
"!Geothermal(Heating/Cooling Supply) residential Water Supply(single) g_ ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
lni ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. W ft J CA P641z E 0 5 E
_ Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERLkL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft
i Experimental Technology Subsidence Control [t. ft
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUmck In etc
i_ Geothermal(Heating/Cooling Return) �_' Other(explain undCejr#21 Rr epmaC�rks ft. [t.
S— 1 v 1 b 1 ft. _
4.Date Well(s)Completed: Wen ID# ft.
ft. ft.
Sa.Well Location:
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Facility/Owner Facility ID/t(if applicable) ft. ft. L
-3 73 �-5R-S:—mcnL 1Z�� bu 13oRc�1 /`1C, [t. [t. v 1 r�rI^
Physical Address,City,and Zip
rZ 5 ol\I zI.REMARKS -
County Parcel Identification No.(PIN) TKO ��E . TO C !'
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees: 1 1�
(if well field,one lat/long is sufficient) 22.Certification:
A,`-I•? 16 "i� N � ?6,glo 0 75 D W `� � 6-� ,2a
6.Is(are)the well(s)EPermanent or OTemporary Signature o erti ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well mvner.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L 5 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@100'and 1Q100) construction to the following:
10.Static water level below top of casing: D (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IZ 61 lg 11 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resonmes,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test (AM 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: hTI-1 Amount: o z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental duality-Division of Water Resources Revised 2-22-2016