GW1-2022-08826_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD(GW-il. For Internal Use Only:
1.Well Contraeto f tion
10 14.WATERZONES ..
FROM TO DESCRIPTION
Well Contractor Name
(J � ft O.�ft
ft 1 ft
NC Well Conti • on Number -I&OUTER.CASING for'mutfiasBederrlls`ORLINER d
able
FROM TO I DIAMETER TRIC[(NESS RlPFMATERIAL
ft ® fr. in. t f C
Company Name
� .16::fNNEIitGAS113"G.OIt:'17IBDdrr:
2.Well Construction Permit#: � �y FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i-e.UIG County,Stare,Variance,eta) f, in.
3.Well Use(check well use): in.
Water Supply Well: FROM tEEN
' FROWfLfft-
Agricultural DIAMETER SLOTSLZE THICKNESS MATERIAL.
13M al/Public 0 in.
Geothermal(Heating/Cooling Supply) Resid=Water Supply(Single) m.
Industrial/Commercial OResidental Water Supply(shared)
.;iS:.GROITC.:
., Irrigation FROM TO MATERIAL EMPLA MENTMETfIOD&AMOUNT
Non-Water Supply Well: ft
Monitoring 131tecovery ft. ft
Injection Well:
ft ft
Aquifer Recharge OGroundwater Remediation 19..SAND/GR&VEL'F'ACK-ff-=tilJczbIe1
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' 13Stormwater Drainage ft
Experimental Technology r3Subsidence Control %
Geothermal(Closed Loop) [3Tracer :2B•• atlachsdditienaliibeets:
FROM I TO D ON aolor,hardness,soWrmk size,eta
Geothermal eatin Cooling ) _ Other(explain under 921 Remarks - ft
4.Date Well(s)Completed: J Well ID# ').5­ft logo fL
Sa Well tin: ft ft
a.
F7,wnerNanic Facility ID#(ifappli le) _
U / ft. ft 11T'n i i3 l 1
Physical City. Zap ., fL. ft
4
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
N W
6.Ware)the well(s) Permanent or Tempo�N.
Sigoanne of Certified Well Contractor Daze
By signing this form,I hereby cenyy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or with 15A NCAC 02C-0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ftff out blown well construction information and explain the nature of the copy ofd us 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 site details or well
construction,only I 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: ©� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple jeeps list all depths ifdifferent(esarnple-3Qa 200 anndd22@100� construction to the following:
10.Static water level below top of casing: J / (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 Injection Wells: In addition to sending the form to the address in 24a
12.Well rnnstractio method above,also submit one copy of this form within 30 days of completion of well
n
(i.e_auger,rotary,cable,direct push,etc.) — — construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test �� 24c For Water Supoly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection type: _ Amount _ Yo 2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of F-nvironmental Quality-Division of Water Resources Revised 2-22-2016