GW1-2022-08752_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informational
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
PLP
NC Well Contractor Certification Number 15.OUTER CASING(for utultI_cuscd.iMls)OR LIN>R(if a licable
4t11 � `n` 1 Y�111 t�1/1 FROM TO DIAMETER THICKINESS MATERAAI
.}-I ft. 'a?� ft. I a in. p,���
Company Name `�`�
16.INNER'CASING OR TUBING ddthcrnial closed466 _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: M SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i_iMunicipal/Public �?�tt, aCPft. a in. C) s_hLlc P\I
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT.
h1i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, a(:) LA l/Z b
qaS
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
39.SAND/GRAVEL PACK(ICa 'licable
D Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test (�_IStormwater Drainage �� ft. 34 ft. .
Experimental Technology FnISubsidence Control ft. ft.
Geothermal(Closed Loop) F11Tracer 20.:DRILLING'UOG(attach addititir al.sh6ets if necessif
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_ Geothermal(Heating/Coolin'gLReturn) (Other(explain under#21 Remarks) ft. � ft. sD; 1
4.Date Wells)Completed: "l— P Well ID# ft. ft.
5a.Well
Location: ft. ft. C
ft. a� ft. ,
`FaciQlity/OwwnnerNaame v C! Facility ID##(iiffatpplilca1b_le) ` f[. ft. �
1�l)� _J�IA� �1�- ern\ VJ r w4t� E'er 11� ft. , ft, C
Ph ical Address,City,and Zip L ft. ft.
r P is: rry,
�y
21.REMARKS s r,r_ �,�. ...�, U, _ t ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f yea.
(if well field,onelat/long is sufficient) 22.Certification: :nti:. �_�yr� 1•'
3�b 59 . O'__5 j��N b W �..� 3;r •o;^ ,3� 1;^,n :; ^fil l
.ruJ lu a6
6.Is(are)the well(s)Vermanent or (®(Temporary Signature of C tified Well ColTactor iDate
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [(Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information atidaplain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: d SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f dierent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: `1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�,d rv� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �(l3ITJ� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I, Method of test: V13T)W'InPr 24c.For Water Supply&Injection Wells: In addition to sending the form to
\� 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ' Y 1 Amount: q CI completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016